Herpes zoster (shingles)

Prescribing Notes:

Consider treatment for anyone aged 50 years and over, age less than 50 years with any of the following criteria:

• Immunocompromised
• non-truncal involvement (such as shingles affecting the neck, face, limbs or perineum)
• involvement of multiple dermatomes
• eczema
• moderate or severe pain
• moderate or severe rash
• seek immediate specialist advice regarding antiviral treatment for people with ophthalmic involvement; severely immunocompromised people; immunocompromised people who are systemically unwell, or have a severe or widespread rash or multiple dermatomal involvement; immunocompromised children; or pregnant or breastfeeding women.

Further notes:

• Aciclovir reduces the symptoms of acute herpes zoster (duration of pain, time to healing of lesions), complications (especially serious eye complications) and may reduce progression to postherpetic neuralgia.
• Valaciclovir is substantially more expensive than aciclovir, therefore it should be used where aciclovir is ineffective or not tolerated.
• Offer a trial of paracetamol alone or in combination with codeine or a non-steroidal anti-inflammatory drug (such as ibuprofen).
• If this is not effective, or the person presents with severe pain, consider offering amitriptyline (off-label use).
• Early use of amitriptyline may prevent or reduce progression to postherpetic neuralgia in elderly patients with acute herpes zoster.

Prescribing Notes:

• Refer children who are immunocompromised and children with suspected complications (such as meningitis, encephalitis or myelitis) urgently for specialist assessment.
• Aciclovir tablets may be dispersed in a minimum of 50ml of water or swallowed whole with a little water. Oral suspension is more expensive, reserve for when dose is <200mg or if tablets are not tolerated.
• See recommendations for ophthalmic zoster.
• Treatment not within 72 hours: consider starting antiviral drug up to one week after rash onset, if high risk of severe shingles or complications (continued vesicle formation; immunocompromised; or severe pain).
• For immunocompetent children with shingles, antiviral treatment is not usually recommended.
• See formulary recommendations for simple analgesia.
• Refer to NICE CKS: Shingles.

Prescribing Notes:

• Available under PGD for patients over 18 who are immunocompetent and have an untreated acute shingles rash on their torso involving a single dermatome and present for less than 72 hours.
• Dispersible tablets are strictly limited to use in patients who are unable to swallow standard tablets.
• Aciclovir reduces the symptoms of acute herpes zoster (duration of pain, time to healing of lesions), complications (especially serious eye complications) and may reduce progression to postherpetic neuralgia.
• Offer a trial of paracetamol alone or in combination with codeine or a non-steroidal anti-inflammatory drug (such as ibuprofen).

Example of counselling points
This medication should be taken with plenty of water.
Advise patient that medication should be taken regularly and must complete the course.
Ensure patient is aware that if symptoms worsen, the patient becomes systemically unwell, or develops a temperature then they should seek medical advice that day either from their own GP or OOH service.
If symptoms have not improved after 7 days treatment, then patients should be advised to seek further medical advice from GP practice.
Self-care - avoid sharing of towels and clothes, maintain good hand hygiene, wear loose fitting clothes to minimise irritation.
Avoid use of topical creams and adhesive dressings as they can cause irritation and delay rash healing.
Shingles is infectious until all the vesicles have crusted over (usually 5-7 days after rash onset). Avoid attending work if the rash is weeping and can’t be covered.
A person who has not had chicken pox or the varicella vaccine can catch chicken pox from a person with shingles (if possible, avoid pregnant women, immunocompromised people and babies younger than 1 month old).

When to advise patient to contact GP
Patient under 18 years of age
Rash affecting areas other than the torso e.g. eyes
Rash involving more than one dermatome
Rash appeared > 72 hours ago
New vesicles formed after 7 days of treatment
Known hypersensitivity to aciclovir or any excipients
Patients with impaired gastro-intestinal absorption
Known immunocompromised patients including those with HIV and patients taking immunosuppressants
Known pregnancy or breastfeeding
Patients who are systemically unwell, including symptoms of fever and headache
Known moderate to severe renal impairment
Recurrent shingles – immunocompetent patient with 2 or more episodes over the person’s lifetime
Severe pain not responding to OTC analgesics
Concomitant use of interacting medication as listed in current BNF