Guidelines for the management of shingles

• British Infection Society •

Investigation

• The diagnosis of herpes zoster is normally made from history and clinical examination
• Advice from an infectious diseases specialist or a virology laboratory may be sought if diagnosis is uncertain on clinical grounds because:
  • rash is atypical in form or site
  • disease is recurrent
  • healing is delayed

Management of acute shingles

Immunocompetent patients

• Provide pain relief as appropriate following the WHO 3-step analgesic ladder
• Oral antiviral drugs in the recommended doses are indicated in the following immunocompetent patients:
  • over the age of 60 years presenting within 72 h of appearance of rash
  • consider also patients under this age who present with severe acute pain within 72 h of rash
  • with ophthalmic involvement in patients of any age within the first 72 h of rash onset
  • with active zoster affecting the neck, limbs and perineum, i.e. cervical, lumbar and sacral dermatomes
• Note – Absence of, or mild, acute pain does not always indicate a low risk of postherpetic neuralgia (PHN)

Immunocompromised patients

• Educate high risk patients to recognise shingles and the importance of early therapy
• Highly immunocompromised patients should receive aciclovir intravenously, and oral therapy can be substituted later depending on the clinical picture. Such patients will require hospital referral
• Other patients can be treated with oral antiviral drugs if shingles is localised and not severe

Management of established PHN

• Take early action in the course of PHN:
  • advise on appropriate clothing – natural fibres such as cotton or silk, and loose-fitting garments
  • consider application of cling film, local anaesthetic or cold packs in appropriate cases with allodynia
  • vibrator and TENS (transcutaneous electrical nerve stimulation) are sometimes useful
  • use analgesic drugs such as paracetamol with or without codeine
  • prescribe amitriptyline 25 mg (10 mg if >65 or frail) taken 1 h before bedtime, increasing weekly by 25 mg (10 mg if > 65 or frail) until pain relief or unacceptable side-effects occur. It is rarely necessary to exceed 75 mg daily
  • if amitriptyline is ineffective, nortriptyline should be tried. If these measures fail, refer patient to a pain clinic
  • gabapentin has been helpful in neuropathic pain, usually guided by a pain clinic