• Prodromal phase of 2-3 days
  • Pain in the affected dermatome
  • Abnormal skin sensations (e.g. pruritus, paraesthesia, dysesthesia, numbness)

 

• Unilateral painful rash in a dermatomal distribution (does not cross midline)
  • Erythematous maculopapular rash for 1-2 days
  • → Vesicles for 3-4 days
  • → Pustules within 1 week
  • → Ulceration and crusting after 3-5 days
  • → Healing over 2-4 weeks, often with scarring and permanent pigmentation

Admit or seek immediate specialist advice if ANY of the following:

• Immunocompromised (severely immunocompromised adult / immunocompromised children)
• Shingles in the ophthalmic distribution of CN V, especially those with:
  • Hutchinson's sign (rash on the nose, representing the dermatome of the nasociliary nerve, is associated with a high complication rate.)
  • Eye pain
  • Photophobia
  • Reduced corneal sensitivity
  • Visual impairment
  • An unexplained red eye
• Head and neck involved (esp. in elderly people)
• Signs of visceral / CNS involvement (including vasculitis)
• Haemorrhagic / necrotic lesions, multisegmental involvement, aberrant vesicles/satellite lesions, mucosal involvement or generalised herpes zoster.

Advise that shingles is infectious until all vesicles have crusted over (~7 days after rash onset).

• Patient should avoid work / school / daycare if the rash is weeping and cannot be covered

Measures to prevent transmission:

• Avoid skin contact with people at high risk of complications 
• Avoid sharing clothes and towels
• Wash their hands often

Skin / rash care measures:

• Avoid touching / scratching the rash 
• Avoid using topical antibiotics and adhesive dressing
• Keep rash clean and dry to reduce risk of bacterial superinfection
• Wear loose fitting clothes 
• Cover lesions that are not under clothes if it is still weeping

Scenarior	Management
Mild to moderate pain	Paracetamol / NSAID  +/- Weak opioid
Moderate to severe pain	Neuropathic pain drugs: Amitriptyline Duloxetine Pregabalin  Gabapentin Also consider oral steroids, but only if immunocompetent and given in combination with antiviral.
If oral treatment not appropriate	Topical capsaicin cream

 

Indications for anit-viral therapy (any of the following):

• Immunocompromised
• >50 y/o
• Non-truncal invovlement
• Moderate / severe pain
• Presence of predisposing skin conditions 

Anti-viral therapy should not be offered to immunocompetent children.

Choice of anti-viral therapy:

• 1st line: oral aciclovir / valaciclovir / famciclovir for 7 days
• To be started within 72 hours of rash onset (if not possible, consider up to 1 week after rash onset)