Herpes Zoster (Shingles) in Primary Care

Publication: 30/09/2010  
Last review: 07/05/2019  
Next review: 31/12/2021  
Clinical Guideline
CURRENT 
ID: 2264 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Herpes Zoster (Shingles) in Primary Care

General Principles for Treating Infections
Grading of guidance recommendations

Herpes zoster (shingles) occurs when there is reactivation of latent VZV infection.

It usually presents as a painful, unilateral vesicular eruption in a dermatomal distribution. Atypical manifestations of herpes zoster may occur in immunocompromised patients, including lesions that are intermittently recurrent, involvement of multiple dermatomes and lesions that appear as chronic crusts or nodules.

There may be acute neuritis of the area affected, with intense pain and associated paraesthesia.

It may be associated with subsequent post-herpetic neuralgia. Post-herpetic neuralgia is rare in patients under 50yrs.

Shingles may cause considerable morbidity, especially in elderly patients, and can be fatal in immunosuppressed patients.

The rate of complications (eg, disseminated disease, ocular involvement) is significantly higher in those who are immunosuppressed (eg transplant recipients, patients receiving some immunomodulating therapies and HIV-infected patients).

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 Preferred Option

Alternative Option

Notes

Analgesia for patients with moderate to severe acute neuritis.

Antiviral therapy for over 50 year olds, or immunocompromised, non-truncal rash, or moderate/severe pain or rash:

Aciclovir  3B+, 5A+
800mg five times a day
7 days 3B+

 

 
If compliance is a problem use:
Valaciclovir  10B+
1g TDS 7 days 10B+

Famciclovir  is classed as Amber level 1, for Aciclovir resistant Herpes Zoster

Seek specialist advice if patient

  • is severely immunocompromised
  • has complicated herpes zoster e.g. Ramsay-Hunt syndrome (herpes zoster oticus) or neurological complications eg encephalitis, myelitis
  • is immunocompromised and is systemically unwell, or has a severe or widespread rash or multiple dermatomal involvement  
  • is an immunocompromised child 
  • is a pregnant or breastfeeding woman
  • has shingles that involves the eye (refer to ophthalmology)

References
Secondary Care Guidelines
CKS
PHE

The management of herpes zoster includes:

  • Analgesia for patients with moderate to severe acute neuritis.
  • Antiviral therapy to hasten healing of cutaneous lesions and to decrease the duration and severity of acute neuritis. Whether antiviral therapy decreases the risk of post-herpetic neuralgia (PHN) is less clear.

Analgesia and other Non-Antiviral Management:

  • Regular paracetamol and ibuprofen are effective in relieving mild to moderate pain and pyrexia, alone or in combination with a weak opioid analgesic.
  • more severe pain may require the addition of strong opioid analgesia.
  • if there is not a rapid response, consider adding another agent such as gabapentin or amitriptyline.
  • chlorphenamine may relieve itch and reduce sleeplessness.
  • corticosteroids should not be used routinely in uncomplicated herpes zoster.

Antiviral therapy  in shingles:

  • patients under 50 years old who are immunocompetent, with localised rash in a truncal distribution, without severe pain/rash, and those presenting more than 72 hrs after onset of rash without new lesions developing or at risk of severe shingles/complications (eg immunocompromised) do not require antiviral treatment.
  • for immunocompetent children with shingles, antiviral treatment is not usually recommended.
  • oral antiviral treatment may be indicated in some immunocompetent and some mildly immunocompromised patients (see below).
  • antiviral treatment is indicated in all patients with ocular or neurological complications; some patients may require intravenous aciclovir
  • severely immunocompromised patients require iv antiviral treatment.

Oral Antiviral treatment:

If specialist advice or referral is not required (see above), start oral antiviral treatment within 72 hours of rash onset for: 

  • Patients aged 50 years and over.
  • Patients aged less than 50 years with any of the following criteria:
    • Immunocompromised (if the level of immunocompromisation is not severe, the rash is localized, the person is not systemically unwell, and they can be closely followed up).
    • Non-truncal involvement (such as shingles affecting the neck, limbs, or perineum).
    • Moderate or severe pain.
    • Moderate or severe rash.
  • If it is not possible to initiate treatment within 72 hours, consider starting an antiviral drug up to one week after rash onset, especially if the person is at higher risk of severe shingles or complications (eg continued vesicle formation, older age, immunocompromised, or in severe pain). 

Oral aciclovir, valaciclovir, or famciclovir are all licensed for use in the treatment of shingles (use clinical judgement, taking into account cost and compliance issues for each individual).

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General Principles for Treating Infections  

This summary table is based on the best available evidence, but use professional judgement and involve patients in management decisions.

1. This summary table should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website.

2. Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.

3. If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection

4. Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice.

5. In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned.

6. Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

7. Limit prescribing over the telephone to exceptional cases.

8. Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example coamoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs.

9. Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited.

10. Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course.

11. Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects.

12. Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity.

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

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Grading of guidance recommendations

The strength of each recommendation is qualified by a letter in parenthesis.

Study design

Recommendation
grade

Good recent systematic review and meta-analysis of studies

A+

One or more rigorous studies; randomised controlled trials

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Non-analytic studies, eg case reports or case series

C

Formal combination of expert opinion

D

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Provenance

Record: 2264
Objective:
Clinical condition:

Shingles (Herpes zoster)

Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

Management of Infection guidance for primary care for consultation and local adaptation


Evidence base

3. Swingler G. Chicken Pox. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:267-79.
RATIONALE: One systematic review was identified that found one RCT (n=148 adults) which compared early versus late administration of aciclovir 800mg five times a day compared with placebo. It found that aciclovir given within 24 hours of the onset of rash significantly reduced the maximum number of lesions (P < 0.01) and the time to full crusting of lesions (P=0.001) compared with placebo. It found no significant difference in time to full crusting of lesions if aciclovir was given 24–72 hours after the rash (P > 0.2).

5. Hope-Simpson RE. Postherpetic neuralgia. Brit J Gen Pract 1975;25:571-75.
RATIONALE: Study showing that incidence of post-herpetic neuralgia in a general practice population increases with age with a third of cases being among those over 80 years.

6. Wood MJ, Shukla S, Fiddian AP, Crooks RJ. Treatment of acute herpes zoster: effect of early (<48 h) versus late (48-72 h) therapy with aciclovir and valaciclovir on prolonged pain. J Infect Dis 1998;127(Suppl 1);S81-S84.
RATIONALE: A study of two databases (n=1076) found no difference in time to complete resolution of zoster-associated pain whether treatment was started within 48 hours or between 48 and 72 hours of the onset of cutaneous herpes zoster. Aciclovir HR 2.2, 95% CI1.03 to 4.71. Valaciclovir HR 1.40, 95% CI 1.04 to 1.87.

7. Wood MJ, Kay R, Dworkin RH, Soong S-J, Whitley RJ. Oral aciclovir therapy accelerates pain resolution in patients with herpes zoster: A meta-analysis of placebo-controlled trials. Clin Inf Dis 1996;22:341-7.
RATIONALE: Meta-analysis of four RCTs (n=691) found greatest benefit in those aged over 50 years, in whom pain resolved twice as fast with aciclovir compared with placebo. Oral aciclovir also reduced the incidence of post herpetic neuralgia.

8. International Herpes Management Forum. Improving the management of varicella, herpes zoster, and zoster-associated pain. 2002. www.ihmf.org Accessed 23.09.14.
RATIONALE: Antiviral treatment is recommended for ophthalmic shingles to prevent the potentially sight-threatening complications than can occur following herpes zoster involving the trigeminal nerve. Aciclovir, famciclovir, and valaciclovir have all been shown to reduce the complications of ophthalmic shingles in RCTs.

9. Dworkin RH, Johnson JW, Bruer J et al. Recommendations for the management of Herpes Zoster. Clin Infect Dis 2007;44(Suppl 1):S1-S26.
RATIONALE: Expert opinion is that treatment of shingles should be considered for non-truncal involvement, people with moderate or severe pain, or those with moderate or severe rash. Evidence from RCTs supports treatment for all those over 50 years to prevent the incidence of post-herpetic neuralgia.

10. Beutner KR, Friedman DJ, Forszpaniak C, Anderson PL, Wood MJ. Valaciclovir compared with aciclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother 1995;39:1546-1553.
RATIONALE: This randomized double-blind controlled trial (n=1141) in people aged 50 years and over within 72 hours of onset of herpes zoster found that valaciclovir 1g three times a day for 7 or 14 days reduced the time to resolution of pain compared with aciclovir 800mg five times a day for 7 days. Median time to cessation of pain was 38 days for valaciclovir for 7 days compared with 51 days for aciclovir (p=0.001), and was 44 days for valaciclovir for 14 days.

11. Shen MC, Lin HH, Lee SS, Chen YS, Chiang PC, Liu YC. Double-blind, randomized, aciclovir-controlled, parallel-group trial comparing the safety efficacy of famciclovir and aciclovir in patients with uncomplicated herpes zoster. J Microbiol Immunol Infect 2004;37:75-81.
RATIONALE: In this small study (n=55), famciclovir and aciclovir were comparable in healing of lesions and cessation of acute-phase pain.

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Document history

LHP version 1.0

Related information

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