Shingles
NICE CKS Shingles. Last revised Nov 2024.
NICE CKS Post-herpetic neuralgia. Last revised: Aug 2024.
Guidelines
Investigation and Diagnosis
Clinical diagnosis – based on typical clinical features.
Clinical Features
- 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
Management
Admission Criteria
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.
General Advice / Conservative Management
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
Pain Management
| Scenario | Management |
|---|---|
| Mild to moderate pain | Paracetamol or NSAID +/- Weak opioid |
| Moderate to severe pain | Neuropathic pain drugs:
+ Consider adjunctive oral steroids (only if immunocompetent and given in combination with antivirals) |
| If oral treatment is not appropriate (+ localised neuropathic pain) | Topical capsaicin cream |
Anti-Viral Therapy
Indications for antiviral therapy (any of the following):
- Immunocompromised
- >50 y/o
- Non-truncal involvement
- Moderate / severe pain
- Presence of predisposing skin conditions
Antiviral 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)
Benefits of oral antivirals in shingles: [Ref]
- Hasten the resolution of skin lesions & reduce the formation of new lesions
- Decrease viral shedding (although do NOT prevent transmission; still contagious)
- Reducing the severity and duration of acute pain
- In older adults and those with moderate-to-severe symptoms, antiviral therapy also lowers the risk of progression to postherpetic neuralgia, although the effect size is modest and not consistently demonstrated in all studies
Prevention
2 doses of Shingrix vaccine are routinely offered to all immunocompetent people at 60 y/o
Currently, it is under a 10-year implementation period.
References
Original Guideline