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Infections and infestations Neurological Skin and nail

Shingles

Last revised in January 2026

Shingles (herpes zoster) is a viral infection of nerve cells that occurs when a latent infection with varicella-zoster virus reactivates.

Shingles: Summary

  • Shingles (herpes zoster) is a viral infection of an individual nerve and the skin surface served by that nerve (dermatome). It is caused by the reactivation of the varicella-zoster virus, the virus which also causes chickenpox.
  • The incidence (and severity) of shingles increase with age. Other risk factors include immunocompromise (for example, due to long-term corticosteroid use, HIV infection, lymphoproliferative malignancies, or chemotherapy treatment), certain comorbidities (such as rheumatoid arthritis and asthma), psychological factors, and female sex. 
  • Post-herpetic neuralgia (defined as pain persisting for, or appearing more than, 90 days after rash onset) is the most common complication of shingles and is more common in older people. Other complications include secondary infection, scarring, ocular complications, and disseminated disease.
  • Assessment of a person with suspected shingles should include:
    • Asking about the symptoms experienced (location, duration, and severity).
    • Identifying risk factors for shingles, such as immunocompromise due to long-term corticosteroid use.
    • Examining the person to assess for clinical features of shingles and to exclude differential diagnoses (such as herpes simplex virus infection and contact dermatitis). 
  • Diagnosis is usually made on clinical grounds.
    • Shingles is characterized by a prodromal period with abnormal skin sensations and pain, followed by a unilateral vesicular rash in the affected dermatome. 
    • The location of symptoms depends on the affected nerve: in immunocompetent people, the infection usually occurs on the thorax, with dermatomes T1 to L2 most commonly affected. In immunocompromised people, symptoms can be more widespread and affect multiple dermatomes (disseminated disease).
    • The rash may be atypical in certain groups of people, for example, older people (in whom the rash may not be vesicular) and immunocompromised people (in whom the rash may be severe or long-lasting). 
  • Management of shingles involves:
    • Arranging hospital admission or seeking immediate specialist advice, where appropriate, for example, if the person is severely immunocompromised, has ophthalmic involvement, is systemically unwell, has a severe or widespread rash or multiple dermatomal involvement, or is an immunocompromised child.
    • Offering oral antiviral treatment, if appropriate.
    • Managing pain. 
    • Offering self-care advice, including advice to avoid contact with people who have not had chickenpox, particularly pregnant women, immunocompromised people, and babies younger than 1 month of age; keep the rash clean and dry; cover lesions while the rash is still weeping; and avoid work, school, or day care if the rash is weeping and cannot be covered. 
    • Considering the need for referral or specialist advice, for example, if antiviral treatment is being considered in a pregnant or breastfeeding woman, new vesicles are forming after 7 days of antiviral treatment, healing is delayed, shingles is recurrent, or pain is inadequately controlled.
  • In the UK, there is a shingles vaccination programme for people:
    • Aged 60 years and older — they remain eligible until their 80th birthday.
    • Aged over 50 years who are immunocompromised — there is no upper age limit.

Have I got the right topic?

From age 12 months onwards.

This CKS topic is largely based on the chapter on Shingles (herpes zoster) in Immunisation against infectious disease (the 'Green book') [UKHSA, 2024], a German consensus guideline S2k guidelines for the diagnosis and treatment of herpes zoster and postherpetic neuralgia [Gross, 2020], the BMJ Best Practice guide Herpes zoster [BMJ Best Practice, 2024a], and expert opinion in a narrative review Recommendations for the management of herpes zoster [Dworkin, 2007].  

This CKS topic covers the management of acute shingles (herpes zoster).

This CKS topic does not cover the management of post-herpetic neuralgia (pain persisting for, or appearing more than, 90 days after rash onset).

There are also separate CKS topics on Chickenpox, Herpes simplex - genital, Herpes simplex - ocular, Herpes simplex - oral, Neuropathic pain - drug treatment, Post-herpetic neuralgia, and Trigeminal neuralgia.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

January 2026 — minor update. Information on eligible cohorts for shingles vaccination has been updated in line with updated NHS guidance.

Previous changes

May 2025 — minor update. QOF indicators updated in line with the NHS England Quality and Outcomes Framework guidance for 2025/26. 

November 2024 — minor update.  Added further link to management of people with shingles of the head and neck advising specialist management or admission to hospital.

September 2024 — minor update.  Information about severely immunosuppressed individuals who received Zostavax prior to becoming immunosuppressed has been added in line with an update to the UKHSA Shingles vaccination guidance.

June 2024 — reviewed.  A literature search was conducted in June 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic.

January 2024 —  minor update. Topic summary changed to advise that people aged over 60 years are now eligible for vaccination.

July 2023 — minor update. Information that the two-dose Shingrix® vaccine will be offered to all people as part of the shingles immunisation programme and that people aged over 60 years are now eligible for vaccination has been added to this topic in line with the UKHSA guidance Shingles vaccination: guidance for healthcare practitioners.  Also the risk factor known as Wegener's granulomatosis has now been changed to granulomatosis with polyangiitis. 

January 2023 — minor update. Tubulointerstitial nephritis added as a potential adverse effect of valaciclovir in line with an update to the manufacturer's summary of product characteristics. 

June 2022 — minor update. Added adverse effect relating to Shingrix from the manufacturer's SPC of a small risk of Guillain-Barre. 

May 2022 — minor update. Information relating to the approach to post-exposure prophylaxis using antiviral treatment for pregnant women and immunocompromised people was added to align with guidance from the UK Health Security Agency Guidelines on post exposure prophylaxis (PEP) for varicella/shingles (April 2022).

August 2021 — minor update. Information relating to the use of the non-live Shingrix® vaccine for immunocompromised individuals from 1st September 2021 was added. 

June 2021 — minor update. Prescribing information for aciclovir has been clarified.

May 2021 — minor update. Information that herpes zoster is an HIV indicator condition has been added to this topic in line with the British HIV Association/British Association for Sexual Health and HIV/British Infection Association Adult HIV testing guidelines 2020.

October 2020 — minor update. A typographical error has been corrected.

October 2019 — reviewed. A literature search was conducted in September 2019 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic. The section on antiviral treatment has been amended to state that antiviral treatment should be considered for all people aged over 50 years. This is based on a Cochrane systematic review which concluded, on the basis of high-quality evidence, that oral aciclovir does not significantly reduce the incidence of post-herpetic neuralgia [Chen, 2014]. The review found insufficient evidence from RCTs to ascertain whether this is also the case for other antiviral drugs.

May 2018 — minor update. Eligible ages for the shingles vaccination has been updated in line with Public Health England (PHE) guidance. See the section on prevention for more information. 

October 2017 — minor update. Seizure has been included as a possible adverse effect of famciclovir.

January 2017 — minor update. Correction made to advice on the use of nonsteroidal anti-inflammatory drug (NSAID) for children with shingles.

November to December 2016 — reviewed. A literature search was conducted in October 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of this topic.

  • Changes to recommendations have been made with respect to the choice of drugs for neuropathic pain in line with the 2013 National Institute for Health and Care Excellence (NICE) guideline Neuropathic pain in adults: pharmacological management in non-specialist settings.
  • New sections have been added on prevalence, risk factors, and differential diagnosis.
  • Minor amendments have been made to the prescribing information section on antiviral drugs.

November 2016 — minor update. Clinical immunosuppression has been specifically highlighted as a contraindication to the administration of shingles vaccine in response to a Medicines and Healthcare products Regulatory Agency (MHRA) Drug safety update Live attenuated vaccines: avoid use in those who are clinically immunosuppressed [MHRA, 2016].

June 2014 — minor update. The text regarding the shingles vaccine has been changed to reflect recent PHE advice regarding eligibility.

October 2012 to May 2013 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. Changes to recommendations have been made with regards to the use of corticosteroids for acute pain, and the use of tramadol whilst awaiting referral to secondary care in those whose pain is not controlled despite all measures available in primary care.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

November 2012 — minor update. The links to the electronic medicines website (www.medicines.org.uk) have been updated.

June 2011— minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

September 2010 — the choice of drug treatment for neuropathic pain has been updated in line with the NICE guideline Neuropathic pain. The pharmacological management of neuropathic pain in adults in non-specialist settings. 

April to June 2010 — updated. The section on management of shingles in immunocompromised people has been updated to clarify that oral antiviral treatment can be considered in primary care if the rash is localized and the person is not systemically unwell or severely immunocompromised. 

April 2009 — minor update to include a link to the CKS topic on Neuropathic pain. 

May to August 2008 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. This topic previously incorporated the management of post-herpetic neuralgia, for which a separate CKS topic is now available. There have been minor changes to the recommendations regarding antiviral treatment.

May 2008 — minor update. Update to the text in medicines management to reflect recent MHRA advice regarding genetic testing for carbamazepine. 

June 2007— update. Gabapentin is now licensed up to a maximum dose of 3600 mg per day for the treatment of peripheral neuropathic pain.

November 2005 — minor technical update. 

February 2005 — reviewed. Validated in June 2005 and issued in July 2005.

December 2001— reviewed and guidance renamed Shingles and postherpetic neuralgia (previously called Herpes zoster). Validated in March 2002 and issued in April 2002.

August 1998 — written.

Update

New evidence

Evidence-based guidelines

  • DHSC (2024) Shingles (herpes zoster) vaccination programme: JCVI statement, November 2024. Department of Health and Social Care. [Free Full-text]
  • UKHSA (2025) Shingles vaccination programme: expansion of Shingrix® vaccine eligibility to all those who are severely immunosuppressed and aged 18 years and over. UK Health Security Agency. [Free Full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 June 2024.

Economic appraisals

No new economic appraisals relevant to England since 1 June 2024.

Systematic reviews and meta-analyses

No new systematic review or meta-analyses since 1 June 2024.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 June 2024.

New policies

No new national policies or guidelines since 1 June 2024.

New safety alerts

No new safety alerts since 1 June 2024.

Changes in product availability

No changes in product availability since 1 June 2024.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

  • Promptly recognise features suggestive of shingles.
  • Make an accurate diagnosis of shingles and exclude differential conditions.
  • Appropriately assess a person with shingles (severity and complications).
  • Offer appropriate management in primary care.
  • Refer to secondary care or other specialist service when necessary.
  • Provide appropriate information and advice to a person with shingles.
  • Advise on the shingles vaccine programme, where appropriate. 

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

Table 1. Indicators related to shingles in the Quality and Outcomes Framework (QOF) 2025/26.

IndicatorPointsPayment stages
VI004 The percentage of patients who reached 80 years old in the preceding 12 months, who have received a shingles vaccine between the ages of 70 and 79 years 1050-60%
Data from: [NHS England, 2025]

QIPP - Options for local implementation

 No QIPP indicators were found during the review of this topic.

NICE Quality standards

No NICE Quality standards were found during the review of this topic.

Background information

What is it?

  • Shingles (herpes zoster) is a viral infection of an individual nerve and the skin surface served by the nerve (dermatome). It is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. 
    • Following a chickenpox infection, which typically occurs during childhood, the varicella-zoster virus lies dormant in the dorsal root ganglia and can reactivate when the immune system is weakened.
    • Unlike chickenpox, which follows the initial infection and causes a generalized rash, shingles generally occurs decades after the primary infection, and symptoms are usually localized to a specific dermatome. 
    • People with active lesions of shingles, particularly if they are immunocompromised, can transmit varicella-zoster virus to susceptible people to cause chickenpox. However, there is no evidence that shingles can be acquired from a person who has chickenpox. 

[UKHSA, 2023; UKHSA, 2024] 

How common is it?

  • The incidence (and severity) of shingles increase with age. 
    • The overall annual incidence in the UK is estimated to be 1.85–3.9 cases per 1000 population, increasing with age from less than two cases per 1000 in people younger than 50 years to 11 cases per 1000 in people aged 80 years or older [BMJ Best Practice, 2024a]. 
    • In people aged 70–79 years, the annual incidence in England and Wales is around 790–880 cases per 100,000 people [UKHSA, 2024].  
  • Incidence is higher in people who are immunosuppressed [Gross, 2020; BMJ Best Practice, 2024a]. 
    • A retrospective cohort study assessed the incidence rate of herpes zoster in people with a wide set of immunocompromised conditions and in immunocompetent people [Yanni, 2018]:
      • The overall incidence rate of shingles in the immunocompromised cohort was 7.8/1000 person-years, increasing with age from 3.5/1000 person-years in people aged 18–49 years to 12.6/1000 person-years in people aged 80 years and older. The incidence rate in the immunocompetent cohort was 6.2/1000 person-years.
      • The proportions of post-herpetic neuralgia and other shingles complications were 10.7% and 2.9% in the immunocompromised cohort and 9.1% and 2.3% in the immunocompetent cohort, respectively.
    • A more recent large population-based retrospective study of people aged 18 years and older in Spain (n = 4,382,590, of which 578,873 were immunocompromised) investigating the incidence of shingles in people with a wide variety of immunocompromised conditions found that [Muñoz-Quiles, 2020]:
      • The incidence ratio (IR) of shingles overall in immunocompromised and immunocompetent people was 5.02, 9.15, and 4.65, respectively.
      • The IR increased with age in both cohorts, and it was higher for all immunocompromised conditions studied, reaching up to 12-fold in people with stem cell transplantation.
  • The lifetime risk of developing shingles is 20–30%, and the risk increases with age [Johnson, 2015; Zorzoli, 2018].

What are the risk factors?

  • Risk factors for shingles include:
    • Increasing age — although shingles can occur at any age, the incidence of the disease (and the risk of complications) increases with age. This is thought to result from an age-related decline in virus-specific, cell-mediated immune responses.
    • Immunocompromise — other conditions that change cell-mediated immunity can increase the risk of shingles (and associated complications). These include HIV infection, lymphoproliferative malignancies, immunosuppressive treatment (such as corticosteroids [long-term use] and chemotherapy), and organ transplantation. 
    • Certain comorbidities, including:
      • Asthma and chronic obstructive pulmonary disease.
      • Cardiovascular disorders.
      • Chronic kidney disease.
      • Depression.
      • Granulomatosis with polyangiitis (previously known as Wegener's granulomatosis).
      • Inflammatory bowel disease. 
      • Malignancies.
      • Neurological disorders. 
      • Psoriasis. 
      • Rheumatoid arthritis.
      • Systemic lupus erythematosus.
      • Type 1 diabetes.
    • Psychological stress — shingles has been linked to physical, emotional, and sexual abuse.  Other contributing factors may include financial stress, inability to work, decreased independence, and an inadequate social support environment.
    • Female sex — females have a greater risk of developing shingles than males.
    • Race/ethnicity — a systematic review and meta-analysis found that black people had almost half the risk of shingles as white people.
  • In addition to increasing age and immunocompromised, other risk factors for complications of shingles include:
    • Severe predisposing skin conditions (for example, atopic dermatitis). 
    • Herpes zoster of the head and/or neck area. 
    • Herpes zoster with:
      • Moderate to severe prodromal or acute zoster‐associated pain.  
      • Severe skin lesions and/or signs of cutaneous dissemination. 
      • Signs of central nervous system involvement. 
      • Signs of visceral involvement. 

[Cohen, 2013; Forbes, 2014; Johnson, 2015; Kawai, 2017; Yanni, 2018; Zorzoli, 2018; Le, 2019; Gross, 2020; Steinmann, 2024; BMJ Best Practice, 2024a]

What are the complications?

  • Post-herpetic neuralgia (pain that persists for, or appears more than, 90 days after rash onset) is the most common complication of shingles and is caused by herpes zoster-induced peripheral nerve damage. See the CKS topic on Post-herpetic neuralgia for more information.
    • It is most common in older people. 
  • Other complications of shingles include:
    • Cardiovascular complications — herpes zoster has been shown to be an independent risk factor for vascular disease, particularly stroke, transient ischaemic attack, and myocardial infarction.
    • Central nervous system (CNS) complications — asymptomatic involvement of the CNS is frequently experienced by people with shingles of the head or neck area, with pathological cerebrospinal fluid (CSF) findings in 60% of cases. CNS complications, such as encephalitis, meningoencephalitis, myelitis, cerebellitis, cerebrovascular disease, radiculitis, and Guillain–Barré syndrome, have been reported, especially in people who are immunocompromised.
    • Herpes zoster ophthalmicus — occurs when the virus infects the ophthalmic division of the trigeminal nerve. Complications include keratitis, corneal ulceration, conjunctivitis, optic neuritis, retinitis, glaucoma, and blindness if untreated. Hutchinson’s sign (a rash on the tip, side, or root of the nose) may be present and indicates nasociliary branch involvement and an increased likelihood of eye inflammation and permanent corneal denervation. Ophthalmic complications occur more frequently and can be more severe in immunocompromised people.
    • Herpes zoster oticus (Ramsay Hunt syndrome) — occurs when the virus infects the facial nerve (cranial nerve VII). It is characterized by lesions in the ear, facial paralysis, and associated hearing and vestibular symptoms.
    • Negative impact on quality of life — the quality of life of a person with shingles can be substantially diminished by both the acute pain associated with the condition and the longer-term, potentially debilitating pain of post-herpetic neuralgia, both of which can limit the person’s productivity and their ability to conduct activities of daily living.
    • Peripheral motor neuropathy — occurs when a motor rather than a sensory nerve is involved, and causes loss of movement in the affected area. It occurs in 5-15% of cases.
    • Skin changes — scarring and changes in pigmentation may occur after a shingles rash has healed.
    • Superinfection of skin lesions — secondary infection of the lesions, usually with staphylococcal or streptococcal bacteria, may occur and can result in cellulitis, osteomyelitis, or life-threatening complications (such as necrotizing fasciitis and sepsis).
  • Systemic dissemination
    • The reactivated virus can, in some cases, disseminate into the lungs, liver, gut, and brain, leading to pneumonia, hepatitis, encephalitis, and disseminated intravascular coagulopathy. 
    • Disseminated disease is more likely to occur in those who are severely immunocompromised, with a case fatality rate reported to be between 5–15% and most deaths being due to pneumonia. 

[Dworkin, 2007; Cohen, 2013; Johnson, 2015; Schmader, 2016; Saguil, 2017; Le, 2019; Ting, 2019; Gross, 2020; BMJ Best Practice, 2024a; UKHSA, 2024]

What is the prognosis?

  • Shingles is usually a self‐limiting disease [Gross, 2020; BMJ Best Practice, 2024a] However, complications may occur if there are risk factors for a complicated course, such as being severely immunocompromised.
  • Recurrent herpes zoster is uncommon in immunocompetent people. Data are conflicting and incidence is uncertain, but it is thought to be higher in people who are immunocompromised [Schmader, 2016; Gross, 2020]. 
  • An Australian population-based cohort study (n=245,805) that examined the recurrence of shingles found that of the 17,413 people (6.8%) who had a first episode of shingles [Qian, 2021]:
    • 3.9% experienced a recurrence.
    • The mean time between first and recurrent zoster was 2 years for those aged 45-54 years and 3 years for those aged 55 years and older.
    • The incidence of recurrence was 11.05 (95% confidence interval, 10.24-11.91) per 1000 person-years, and higher recurrence incidence occurred in women compared to men, in younger compared to older participants, and in immunosuppressed compared to immunocompetent people.
    • Recurrence appeared lower in the 12 months after onset but then remained consistent at approximately 12.00 per 1000 person-years in the following 8 years.
  • A large population-based retrospective study of people aged 18 years and older in Spain (n = 4,382,590, of which 578,873 were immunocompromised) investigating the incidence of shingles in people with a wide variety of immunocompromised conditions found that [Muñoz-Quiles, 2020]:
    • Immunocompromised people had a 51% higher risk of developing shingles and a 25% higher recurrence.
    • The risk of complications was 2.37 times higher compared to immunocompetent people.

Diagnosis of shingles

What are the clinical features of shingles?

  • Shingles is normally preceded by a prodromal phase (typically lasting for 2-3 days, although it can last for 7 days or more) with:
    • Abnormal skin sensations (such as pruritus, paraesthesia, dysesthesia and numbness).
    • Pain in the affected dermatome.
      • The pain can be described as burning, shooting, stabbing, throbbing or pulsating. It can be intermittent or constant, and may be so severe it interferes with sleep and quality of life. 
  • A unilateral erythematous maculopapular rash then typically appears in a dermatomal distribution — the rash is usually accompanied by the same pain experienced during the prodrome, but this acute pain can worsen, improve, or appear for the first time.   
    • Erythematous macules and papules develop into vesicles within 1-2 days, with new vesicles continuing to form over 3–4 days.
    • Pustulation of vesicles occurs within one week of rash onset (if not sooner), followed by ulceration and crusting after 3-5 days. 
    • Healing occurs over 2–4 weeks, and often results in scarring and permanent pigmentation in the affected area. 
  • Note: the rash may be atypical in certain groups of people, for example older people (in whom the rash may not be vesicular) and immunocompromised people (in whom the rash may be severe or long-lasting). 
  • Around 20% of people present with systemic symptoms, such as headache, fever, malaise or fatigue. 
  • The location of symptoms depends on the affected nerve:
    • In immunocompetent people, the infection usually occurs on the thorax, with dermatomes T1 to L2 most commonly affected. 
    • In immunocompromised people, symptoms can be more widespread and affect multiple dermatomes (disseminated disease). 
  • Note: in rare cases, pain without a rash (zoster sine herpete) can occur. 

Basis for recommendation

This information is based on a German consensus guideline S2k guidelines for the diagnosis and treatment of herpes zoster and postherpetic neuralgia [Gross, 2020], the chapter on Shingles (herpes zoster) in Immunisation against infectious disease (the 'Green book') [UKHSA, 2024], the BMJ Best Practice guide Herpes zoster [BMJ Best Practice, 2024a], and expert opinion in narrative reviews Recommendations for the management of herpes zoster [Dworkin, 2007], Herpes zoster [Schmader, 2016], Herpes zoster and postherpetic neuralgia: prevention and management [Saguil, 2017], and Herpes zoster infection [Le, 2019]. 

How should I assess a person with suspected shingles?

  • Take a history and ask about: 
    • Signs and symptoms of shingles, including timing, location, duration, and severity.
    • Other signs and symptoms — for example, fever, headache, malaise, or fatigue. 
    • Risk factors for severe disease and complications.
  • Examine the person to: 
  • Diagnose shingles on the basis of typical clinical features. 
  • Investigations are not usually required in primary care. If there is diagnostic uncertainty, refer or seek specialist advice.

Basis for recommendation

These recommendations are based on a German consensus guideline S2k guidelines for the diagnosis and treatment of herpes zoster and postherpetic neuralgia [Gross, 2020], the BMJ Best Practice guide Herpes zoster [BMJ Best Practice, 2024a], expert opinion in a narrative review Recommendations for the management of herpes zoster [Dworkin, 2007], and what prodigy considers good medical practice. 

Investigations
  • Investigations are not normally necessary, as diagnosis is primarily based on clinical features [BMJ Best Practice, 2024a; Dworkin, 2007], but may be considered [Saguil, 2017; Le, 2019; Gross, 2020]:
    • In people with recurring lesions that are suspicious for herpes simplex. 
    • In people with suspected zoster sine herpete, in which the virus causes pain without lesions.
    • In people who have received a varicella-zoster virus vaccine. 
    • For atypical presentations, such as the widely disseminated lesions that may occur in immunocompromised people.
    • For differentiating herpes zoster from other vesicular dermatoses, such as contact dermatitis. 
  • Investigations that may be used to diagnose shingles include polymerase chain reaction testing of vesicle or other body fluids to identify varicella-zoster virus DNA, immunohistochemical analysis of skin scrapings, or virus culture [Saguil, 2017; Le, 2019; Gross, 2020; BMJ Best Practice, 2024a].

What else might it be?

  • Differential diagnoses of shingles include:
    • Herpes simplex virus (HSV) infection — this can also present with a unilateral, red, maculopapular, vesicular rash and acute pain. Features which are more likely to indicate HSV infection include multiple recurrences (around the mouth or genital areas) and lack of chronic pain. See the CKS topics on Herpes simplex - genital and Herpes simplex - oral for more information.
    • Candidal skin infection — the appearance of the skin is variable, depending on the affected area. Soreness and itching is usual. Thin-walled pustules with a red base may be present. Scales may accumulate, producing a white-yellow, curd-like substance over the infected area. See the CKS topic on Candida - skin for more information.
    • Contact dermatitis — localized rash or irritation of the skin caused by contact with a foreign substance. The pain and the rash usually occur simultaneously. See the CKS topic on Dermatitis - contact for more information.
    • Primary HIV infection — herpes zoster is an HIV indicator condition. For more information, see the CKS topic on HIV HIV infection and AIDS.
    • Impetigo — presents with vesicles, which can rupture and crust. See the CKS topic on Impetigo for more information.
    • Insect bite or sting — there may be local symptoms (such as pain, swelling, and erythema) and symptoms that may indicate a systemic reaction (such as urticaria, rhinitis, wheezing, abdominal pain, vomiting, and dizziness). See the CKS topic on Insect bites and stings for more information.
    • Scabies — an intensely itchy skin infestation characterized by symmetric erythematous papules, often excoriated, seen in a characteristic pattern. See the CKS topic on Scabies for more information.
    • Urticaria — a superficial swelling of the skin (epidermis and mucous membranes) that results in a red, raised, itchy rash. See the CKS topic on Urticaria for more information.
  • Differential diagnoses of herpes zoster ophthalmicus include:
    • Acute angle closure glaucoma — characterized by periorbital pain, blurred vision, and headache. See the CKS topic on Glaucoma for more information.
    • HSV ocular infections — characterized by eye pain, blurred vision, an acute red eye, and crops of vesicles, ulcers, or pustules along the lid margin or periocular skin. HSV ocular infections can cause retinitis, iritis or uveitis, keratitis, conjunctivitis, blepharitis, and periocular dermatitis. See the CKS topic on Herpes simplex - ocular for more information.
    • Trigeminal neuralgia — characterized by intense, stabbing, electric shock-like pain in the areas of the face innervated by the trigeminal nerve. There may be an obvious trigger area for the pain. See the CKS topic on Trigeminal neuralgia for more information.
    • Ulcerative keratitis — symptoms depend on the cause. The person may present with pain and redness in the affected eye, with visual changes depending on the ulcer location.
  • The prodromal pain of shingles can often mimic other conditions, depending on the site of infection, including: 
    • Acute appendicitis — characterized by pain in the right lower abdominal quadrant. See the CKS topic on Appendicitis for more information.
    • Cholecystitis — characterized by pain in the right upper quadrant of the abdomen, accompanied by nausea, vomiting, and fever. Upon examination, the person may have Murphy's sign. See the CKS topic on Cholecystitis - acute for more information.
    • Migraine — characterized by attacks of moderate or severe headache and associated symptoms, such as photophobia, phonophobia, nausea, and vomiting. See the CKS topic on Migraine for more information.
    • Renal calculi — characterized by severe colicky pain and inability to lie still, and flank pain on examination. See the CKS topic on Renal or ureteric colic - acute for more information.

Basis for recommendation

This information is based on a German consensus guideline S2k guidelines for the diagnosis and treatment of herpes zoster and postherpetic neuralgia [Gross, 2020], the BMJ Best Practice guide Herpes zoster [BMJ Best Practice, 2024a], and expert opinion in narrative reviews Recommendations for the management of herpes zoster [Dworkin, 2007], Herpes zoster [Schmader, 2016], and Herpes zoster infection [Le, 2019].

Management

Scenario: Management

From age 12 months onwards.

How should I manage a person with shingles?

  • Admit to hospital (or seek immediate specialist advice) if: 
    • Serious complications (such as meningitis, encephalitis, or myelitis) are suspected. 
    • The person has shingles in the ophthalmic distribution of the trigeminal nerve, especially those with:
      • Hutchinson's sign — a rash on the tip, side, or root of 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. For more information, see the CKS topic on Red eye.
    • The head and neck are affected, especially in elderly people. 
    • There are haemorrhagic/necrotic lesions, multisegmental involvement, aberrant vesicles/satellite lesions, mucosal involvement or generalized herpes zoster.
    • The person is severely immunosuppressed. 
    • An immunocompromised child has shingles.
    • There are signs of visceral or central nervous system (CNS) involvement (including vasculitis).
  • For all other people with shingles:
    • Consider the need for oral antiviral treatment. See the section on Antiviral treatment for more information.
    • Manage pain. See the section on Pain management for more information.
    • Give appropriate information and advice. See the section on Information and advice for more information.
    • Refer, or seek specialist advice if:
      • New vesicles are forming after 7 days of oral antiviral treatment, or healing is delayed. 
      • A person who is thought to be immunocompetent has had two episodes of shingles. 
      • Shingles recurs in an immunocompromised person.
      • Pain is inadequately controlled by oral analgesia, or a strong opioid (such as morphine) is being considered. 
  • Use clinical judgment to decide who to consult or refer to (for example, ophthalmology, dermatology, obstetrics, immunology, or pain specialist, depending on the presenting problem) and the urgency, depending on the risk to the person and their clinical condition.

Basis for recommendation

These recommendations are based on a German consensus guideline S2k guidelines for the diagnosis and treatment of herpes zoster and postherpetic neuralgia [Gross, 2020], the BMJ Best Practice guide Herpes zoster [BMJ Best Practice, 2024a], expert opinion in a narrative review Recommendations for the management of herpes zoster [Dworkin, 2007], and what CKS considers good medical practice. 

Admission or specialist advice
  • The recommendations on when to admit or refer people are largely based on a German consensus guideline which recommends intravenous aciclovir treatment for people at risk of a complicated disease course, including the following circumstances [Gross, 2020]:
    • Head and neck involvement, especially in elderly people.
    • Haemorrhagic/necrotic lesions, multisegmental involvement, aberrant vesicles/satellite lesions, mucosal involvement, or generalized herpes zoster.
    • Immunosuppressed people.
    • Signs of visceral or CNS involvement (including vasculitis).
Immunosuppression
  • Expert opinion in a narrative review is that intravenous aciclovir is the drug of choice for people who are severely immunocompromised and that for less severely immunosuppressed people, oral therapy with antivirals is a reasonable option [Dworkin, 2007]. The BMJ Best Practice guide [BMJ Best Practice, 2024a] also recommends oral antiviral therapy for people who are not severely immunocompromised if there is no eye involvement. However, a German consensus guideline recommends intravenous aciclovir for all people who are immunosuppressed [Gross, 2020]. 
  • CKS considers that clinical judgment should be used to determine management in people who are immunosuppressed.  
Referral
  • The recommendations on referral and seeking expert advice are based on expert opinion in a narrative review, a German consensus guideline and what CKS considers good medical practice.
    • Occurrence of new vesicles after one week should raise concerns about an underlying immunodeficiency syndrome [Dworkin, 2007].  
    • Recurrent herpes zoster is uncommon in immunocompetent people and further investigation is recommended [Gross, 2020].

When should I offer oral antiviral treatment to people with shingles?

  • If admission or immediate specialist advice is not indicated, consider the need for oral antiviral treatment. 
  • Offer oral aciclovir, valaciclovir, or famciclovir within 72 hours of rash onset to:
    • People who are immunocompromised (based on clinical judgement, for example, if the level of immunocompromise is not severe, the rash is localized, there is no eye involvement, the person is not systemically unwell, and they can be closely followed up).
      • Refer people who are severely immunocompromised for intravenous aciclovir treatment. 
    • People aged 50 years and over.  
    • People with non-truncal involvement (excluding the head and neck, where admission or specialist advice is indicated). 
    • People with moderate or severe pain or moderate or severe rash. 
    • People with predisposing skin conditions.
  • Consider offering antiviral treatment to other people aged under 50 years with shingles of the extremities or the trunk depending on clinical judgement. 
  • If it is not possible to initiate treatment within 72 hours, consider starting antiviral treatment up to one week after rash onset, especially if the person is at higher risk of severe shingles or complications (for example continued vesicle formation, signs of cutaneous, visceral or neurological dissemination, older age, immunocompromised, or in severe pain). 
  • Note: antiviral treatment is not recommended in immunocompetent children. 
  • If a pregnant or breastfeeding woman has shingles, seek specialist advice before prescribing antiviral treatment.

Basis for recommendation

These recommendations are based on a German consensus guideline S2k guidelines for the diagnosis and treatment of herpes zoster and postherpetic neuralgia [Gross, 2020], the BMJ Best Practice guide Herpes zoster [BMJ Best Practice, 2024a], expert opinion in a narrative review Recommendations for the management of herpes zoster [Dworkin, 2007], the manufacturers' Summaries of Product Characteristics (SPCs) for aciclovir [EMC, 2023a], famciclovir [EMC, 2023b], and valaciclovir [EMC, 2024a], and what CKS considers good medical practice. 

Offering antiviral treatment
  • Expert consensus in a narrative review is that systemic antiviral therapy is strongly recommended as first-line treatment for immunocompetent people with shingles if they are aged 50 years or over, have moderate or severe pain, have a moderate or severe rash, or have non-truncal involvement. It also advises that antiviral treatment can be considered in people at low risk of complications as antivirals are exceptionally safe [Dworkin, 2007]. 
  • This approach is supported by a German consensus guideline, which recommends antiviral treatment for people who are immunocompromised, aged 50 years or over, have moderate to severe pain, head and/or neck involvement, haemorrhagic or necrotizing lesions, aberrant vesicles/satellite lesions, multisegmental involvement, or mucocutaneous involvement, if they have predisposing skin diseases (for example, atopic dermatitis), or for children and adolescents on long-term treatment topical corticosteroid treatment. It also suggests that antiviral therapy can be considered in people at low risk of sequelae or complicated disease as there is a relatively low risk of adverse effects associated with antiviral medicines [Gross, 2020]. 
  • The BMJ Best Practice Guide recommends that antivirals should be considered in all people, especially those who are immunocompromised, have severe disease, or are aged over 50 years [BMJ Best Practice, 2024a].  
  • The German consensus guideline recommends intravenous aciclovir for people with complicated shingles or who are at risk of complications [Gross, 2020]. Expert opinion in the narrative review is that intravenous aciclovir is the therapy of choice in people who are severely immunocompromised, and that for less severely immunocompromised people oral therapy with an antiviral coupled with close observation is a reasonable option [Dworkin, 2007]. The BMJ Best Practice guide recommends reserving intravenous aciclovir for people with disseminated varicella zoster virus infection, ophthalmic involvement, very severe immunosuppression, or who are unable to take oral medicines [BMJ Best Practice, 2024a].
Immunosuppression
  • Expert opinion in a narrative review is that intravenous aciclovir is the drug of choice for people who are severely immunocompromised and that for less severely immunosuppressed people, oral therapy with antivirals is a reasonable option [Dworkin, 2007]. The BMJ Best Practice guide [BMJ Best Practice, 2024a] also recommends oral antiviral therapy for people who are not severely immunocompromised if there is no eye involvement. However, a German guideline recommends intravenous aciclovir for all people who are immunosuppressed [Gross, 2020]. 
Pregnancy or breastfeeding
  • The recommendation to seek specialist advice before prescribing an antiviral in pregnancy is pragmatic based on what CKS considers good medical practice. 
    • The German consensus guideline advises that antiviral medication is not recommended in pregnant women in the absence of complications, and if it is being considered, the benefits for the mother need to be considered along with the potential risks to the fetus [Gross, 2020], while the BMJ Best Practice guide advises that treatment during pregnancy is the same as treatment for any other person with shingles, and that aciclovir has been most extensively studied in pregnant women and is the most commonly used [BMJ Best Practice, 2024a].
Choice of antiviral
  • A systematic review and meta-analysis that compared the effectiveness of antivirals in the management of herpes zoster found that [McDonald, 2012]: 
    • Compared with aciclovir, valaciclovir showed significant reduction in herpes-zoster-associated pain up to 112 days, with the largest reduction in pain (36%) at 21-30 days.
    • Famciclovir was also superior to aciclovir, with a 46% reduction in risk of pain at 28-30 days.
    • Time to lesion healing and adverse effect profiles were comparable.
  • A German consensus guideline advises that a shared decision-making approach should be used to decide the choice of antiviral, and dosing regimens, comorbidities, drug interactions and costs should also be considered [Gross, 2020].

How should I manage the pain of shingles?

  • For adults with:
    • Mild to moderate pain, offer paracetamol or a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen alone or in combination with a weak opioid (such as codeine). 
    • Moderate to severe pain, offer a choice of amitriptyline (off-label use), duloxetine (off-label use), gabapentin, or pregabalin. 
  • Consider offering capsaicin cream for people with localised neuropathic pain who wish to avoid or who cannot tolerate oral treatments.  
  • Consider oral corticosteroids [in the first 2 weeks following rash onset] in immunocompetent adults with localized shingles if pain is severe, but only in combination with antiviral treatment.
    • Use clinical judgment, taking into account the risks and benefits of corticosteroid therapy for each person. See the CKS topic on Corticosteroids - oral for information on prescribing oral corticosteroids. 
  • Seek specialist advice or refer to the pain team if: 
    • Pain is inadequately controlled by oral analgesia.
    • A strong opioid (such as morphine) is being considered.
  • If there is persisting pain after the resolution of skin lesions, see the CKS topic on Post-herpetic neuralgia for management information.
  • For children with pain, offer a trial of paracetamol (avoid the use of NSAIDs). 
    • If this is not effective, seek specialist advice.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Neuropathic pain in adults: pharmacological management in non-specialist settings [NICE, 2020], the BMJ Best Practice guide Herpes zoster [BMJ Best Practice, 2024a], and what CKS considers good medical practice. 

Corticosteroids 
  • Expert opinion in a narrative review is that corticosteroids can be considered as soon as possible after diagnosis for people with at least moderately severe pain and no contraindications, and it should only be initiated in combination with antiviral therapy [Dworkin, 2007]. This is supported by another review that advises that if corticosteroid treatment is being considered it should always be with antiviral therapy [Schmader, 2016]. However, another review advises that the use of corticosteroids to treat acute pain is controversial, and the risks of using them may outweigh any potential benefits in some people, but if they are used they should only be given in combination with an antiviral [Cohen, 2013].
  • The BMJ Best Practice guide advises that corticosteroids are an appropriate option for people with moderate to severe post-herpetic pain who are intolerant of opioids or at high risk of addiction [BMJ Best Practice, 2024a]. However, the German consensus guideline does not recommend use of corticosteroids (or against them), but advises that acute herpes-zoster-associated pain should be treated according to the WHO pain relief ladder [Gross, 2020]. 
  • Also of note is that a recent Cochrane review which assessed the effects of corticosteroids in preventing postherpetic neuralgia, found that there was uncertainty about the effects of oral corticosteroids in preventing postherpetic neuralgia 6 months after the onset of herpes zoster [Jiang, 2023].   
  • CKS could not find sufficient evidence to support a recommendation for oral corticosteroids for the treatment of acute pain in people with shingles, so the recommendation to consider offering corticosteroids based on clinical judgment is pragmatic.  
Avoidance of NSAIDs in children
  • The recommendation to avoid use of NSAIDs in children with shingles is pragmatic, as use of NSAIDs in children with varicella zoster virus is associated with an increased risk of severe skin and soft tissue complications (group A streptococcus superinfection) [Mikaeloff, 2007; BMJ Best Practice, 2024b].

What information and advice should I give a person with shingles?

  • Explain that people with active lesions, particularly if they are immunosuppressed, can transmit the virus to susceptible people (who have not had chickenpox or the varicella vaccine) to cause chickenpox.
    • The person with shingles is infectious until all the vesicles have crusted over (approximately 7 days after rash onset).  
  • Advise people with shingles to:
    • Avoid skin contact with people at high risk of complications (for example, immunocompromised people, newborn babies, and elderly people), and people who have not had chickenpox (especially pregnant women) until the rash crusts over.
    • Avoid sharing clothes and towels. 
    • Avoid touching or scratching the rash.
    • Wash their hands often. 
    • Wear loose-fitting clothes to reduce irritation. 
    • Cover lesions that are not under clothes while the rash is still weeping.
    • Avoid use of topical antibiotics and adhesive dressings, as they can cause irritation and delay rash healing. 
    • Keep the rash clean and dry to reduce the risk of bacterial superinfection. They should seek medical advice if there is an increase in temperature, as this may indicate bacterial infection.
    • Avoid work, school, or daycare if the rash is weeping and cannot be covered. 
  • Provide additional sources of information, advice, and support. 

Basis for recommendation

These recommendations are based on the chapter on Shingles (herpes zoster) in Immunisation against infectious disease (the 'Green book') [UKHSA, 2024], the British Association of Dermatologists (BAD) leaflet Shingles (Herpes zoster) [BAD, 2020], the U.S. Centres for Disease Control and Prevention (CDC) patient information Shingles (herpes zoster) [CDC, 2024], the NHS patient information Shingles [NHS, 2023], and the NHS Inform patient information Shingles [NHS Inform, 2023].   

Scenario: Prevention

From age 70 years onwards.

How can shingles be prevented?

  • The shingles vaccination programme aims to reduce the incidence and severity of shingles disease in adults aged 60 years and older, in whom the risk and severity of disease and of subsequent post-herpetic neuralgia is higher.
    • When it was introduced the programme offered vaccination to people aged 70 years and older, but in 2023 it was expanded to offer vaccination to people aged 60 years of age — this is being undertaken in a phased approach over 2 stages during a 10-year implementation period. Thereafter, it will be offered routinely to all immunocompetent people at 60 years of age.
  • Offer two doses of Shingrix® vaccine to the following if they have not previously received it:
    • People aged 70-79 years (the second dose can be given until their 81st birthday). 
      • Immunocompetent people remain eligible for the shingles vaccine until their 80th birthday.
    • People aged over 60 years (as they become eligible).
      • Stage 1 (1 September 2023 to 31 August 2028) — people turning 70 and those turning 65 years as they become eligible.
      • Stage 2 (1 September 2028 to 31 August 2033) — people turning 65 and those turning 60 years as they become eligible.
      • Note: if the second dose is due after their 80th birthday, they will be eligible to receive this up until their 81st birthday.
    • People aged over 18 years who are severely immunocompromised.   
      • Note: there is no upper age limit for these people. 
  • For more information, see the prescribing information section on Shingrix®. 
  • Immunocompetent and mildly immunosuppressed individuals who were given Zostavax prior to becoming eligible for the national programme should be offered the vaccine when they reach the eligible age for the routine programme, leaving one year since they received the Zostavax vaccine.
  • For information on management of post-exposure prophylaxis for varicella-zoster virus, see the section on Significant exposure in the CKS topic on Chickenpox.

Basis for recommendation

These recommendations are based on the chapter on Shingles (herpes zoster) in Immunisation against infectious disease (the 'Green book') [UKHSA, 2024], the UK Health Security Agency (UKHSA) guideline Shingles immunisation: information for healthcare professionals [UKHSA, 2023], and the NHS England General practice shingles vaccination programme technical guidance [NHS England, 2023]. 

Dosage interval
  • Two doses of 0.5ml of Shingrix® should be given a minimum of 8 weeks apart. However, for operational reasons in England, Wales and Northern Ireland a longer dose interval of 6-12 months is used, while in Scotland an interval of 2-6 months is used [UKHSA, 2024]. 
Vaccine effectiveness
  • A population-based study [Andrews, 2020] that assessed the impact of herpes zoster vaccination in the 5 years after introduction for people aged 70-79 years found large and prolonged reductions in herpes zoster and postherpetic neuralgia (PHN) consultations and hospitalizations were observed in the 5 years post-implementation.
    • In 79 year-olds first eligible in 2013, the incidence rate ratio for consultations 5 years later was 0·65 (95% CI:0·52 to 0·81). Over the whole period an estimated 40,500 fewer zoster consultations and 1840 fewer zoster hospitalizations occurred because of the vaccination programme. These reductions were consistent with effectiveness in the routine cohorts (vaccinated aged 70) of between 37% (for hospitalized zoster) and 75% (for PHN consultations) and, in catch up cohorts (vaccinated aged 78 to 79) of between 49% (for hospitalized PHN) and 66% (for PHN consultations).
  • A Cochrane systematic review of 26 studies (n = 90,259) that evaluated the effectiveness and safety of vaccination to prevent herpes zoster in older adults found that a single dose of the live attenuated zoster vaccine and two doses of a recombinant zoster vaccine are probably effective in preventing shingles disease for at least 3 years [de Oliveira Gomes, 2023]. 
  • In the first real-world assessment of vaccine effectiveness of the UK vaccine programme, effectiveness waned from 69% (95% CI 65-74%) in the first year after vaccination to 45% (95% CI 29-57%) by the third year [UKHSA, 2024]. 
  • In the phase 3 randomized placebo-controlled clinical trials of 15,411 participants, vaccine efficacy in the 7,695 immunocompetent adults aged 50 years and over, and 6,950 aged 70 years and over, administered with two doses of Shingrix® 2 months apart was estimated at 97.2% and 91.2% respectively, while one and two dose real-world vaccine effectiveness was estimated at 56.9% and 70.1% respectively in a US study of adults aged over 65 years [UKHSA, 2024].
    • Two-dose vaccine effectiveness against PHN was 76.0% (95% CI, 68.4-81.8). The two-dose vaccine effectiveness was not significantly lower for adults aged over 80 years, for second doses received at 180 days or more, or for individuals with autoimmune conditions.
Individuals aged 18 to 49 years who have received a stem cell transplant
  • People aged 18 to 49 years who have had a stem cell transplant are eligible to receive two doses of Shingrix® vaccine (8 weeks to 6 months apart). However, this cohort is not part of the national routine vaccination schedule [NHS England, 2023].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) or the British National Formulary (BNF).

Aciclovir

Dose

  • In adults, prescribe 800 mg five times daily (at approximately 4-hour intervals) for 7 days. 
    • For immunocompromised people continue for 2 days after the lesions have crusted. 
  • If estimated glomerular filtration rate (eGFR) is:
    • 10–25 mL/minute/1.73 m2, reduce the dose to 800 mg every 8 hours.
    • Less than 10 mL/minute/1.73 m2, reduce the dose to 800 mg every 12 hours.

[EMC, 2023a; BNF, 2024] 

Contraindications and cautions

  • Prescribe aciclovir with caution to:
    • People with renal impairment — dose reductions may be necessary.  
    • Elderly people.

[EMC, 2023a; BNF, 2024] 

Adverse effects

  • Gastrointestinal 
    • Common: nausea, vomiting, diarrhoea, abdominal pain.
  • Psychiatric and nervous system
    • Common: headache, dizziness.
    • Very rarely: agitation, confusion, ataxia, hallucinations, convulsions, psychotic symptoms, coma.
  • Skin and subcutaneous tissue 
    • Common: pruritus, rashes. 
    • Uncommon: urticaria, accelerated hair loss.
    • Rarely: angioedema.
  • Rare or very rare adverse effects include:
    • Anaphylaxis.
    • Anaemia, leucopenia, thrombocytopenia.
    • Dyspnoea.
    • Increases in blood urea and creatinine, acute renal failure.
    • Liver enzyme increases, hepatitis, and jaundice.

[EMC, 2023a; BNF, 2024] 

Drug interactions

  • Aminophylline and theophylline — aciclovir can increase the plasma concentrations of theophylline. Be alert for signs of adverse effects. 
  • Mycophenolate — clinically important pharmacokinetic changes may occur in people with impaired renal function. Monitor in people with reduced renal function.
  • Tacrolimus — concurrent use may cause additive nephrotoxicity. Monitor tacrolimus concentrations and effects.  
  • Voclosporin —  concurrent use may cause additive nephrotoxicity. If concurrent use is unavoidable, monitor renal function more frequently.   
  • Live herpes-zoster vaccine — vaccine efficacy may be affected. Avoid live herpes-zoster vaccines until at least 48 hours after stopping aciclovir. If possible, avoid aciclovir for 2 weeks after live herpes-zoster vaccines. 

[Preston, 2024]

Famciclovir

Dose

  • In adults, prescribe 500 mg three times daily (or 750 mg 1–2 times daily) for 7 days.
    • For immunocompromised people, prescribe 500 mg three times daily for 10 days, and continue for 2 days after the lesions have crusted.
  • If creatinine clearance (CrCl) is:
    • 40–59 mL/minute, reduce the dose to 500 mg twice daily.
    • 20–39 mL/minute, reduce the dose to 500 mg once daily.
    • Less than 20 mL/minute, reduce the dose to 250 mg once daily.

[EMC, 2023b; BNF, 2024]

Contraindications and cautions

  • Prescribe famciclovir with caution to people with:
    • Renal impairment.
    • Hepatic impairment. 

[EMC, 2023b; BNF, 2024]

Adverse effects

  • Gastrointestinal  
    • Common: nausea, vomiting, abdominal pain, and diarrhoea.
  • Nervous system
    • Very common: headache.
    • Common: dizziness.
  • Skin and subcutaneous tissue
    • Common: rash, pruritus.
    • Unknown frequency: erythema multiforme, Stevens-Johnson Syndrome, toxic epidermal necrolysis, hypersensitivity vasculitis.
  •  Other adverse effects include:
    • Abnormal liver function tests, cholestatic jaundice.
    • Confusional state (predominantly in the elderly), somnolence.
    • Palpitations. 

[EMC, 2023b; BNF, 2024]

Drug interactions

  • Live herpes-zoster vaccine — vaccine efficacy may be affected. Avoid live herpes-zoster vaccines until at least 48 hours after stopping famciclovir. If possible, avoid famciclovir for 2 weeks after live herpes-zoster vaccines. 

[Preston, 2024]

Valaciclovir

Dose

  • In adults, prescribe 1000 mg three times daily for 7 days.
    • In immunocompromised people prescribe 1000 mg three times daily for at least 7 days and continue treatment for 2 days after the lesions have crusted. 
  • If estimated glomerular filtration rate (eGFR) is:
    • 30–50 mL/minute/1.73 m2, reduce the dose to 1000 mg twice daily.
    • 10–30 mL/minute/1.73 m2, reduce the dose to 1000 mg once daily.
    • Less than 10 mL/minute/1.73 m2, reduce the dose to 500 mg once daily.

[BNF, 2024; EMC, 2024a]

Contraindications and cautions

  • Prescribe valaciclovir with caution to:
    • People with renal impairment — dose adjustments may be necessary.
    • The elderly — there is a risk of neurological reactions. 
      • Maintain adequate hydration.

[BNF, 2024; EMC, 2024a]

Adverse effects

  • Gastrointestinal
    • Common or very common: nausea, vomiting, diarrhoea.
    • Uncommon: abdominal discomfort.
  • Psychiatric and nervous system
    • Common or very common: dizziness, headache.
    • Uncommon: hallucinations, agitation, tremor, confusion. 
      • Neurological disorders, sometimes severe, may be linked to encephalopathy and include confusion, agitation, convulsions, hallucinations, coma. These events are generally reversible and usually seen in patients with renal impairment or with other predisposing factors.
  • Renal and urinary disorders
    • Uncommon: haematuria, renal pain.
    • Rarely: renal impairment, acute renal failure (especially in elderly people or in people with renal impairment receiving higher than the recommended doses). 
  • Skin and subcutaneous tissue
    • Common: rashes (including photosensitivity), and pruritus. 
    • Unknown frequency: drug reaction with eosinophilia and systemic symptoms (DRESS). 
  • Other adverse effects include:
    • Abnormal liver function tests. 
    • Dyspnoea.
    • Leucopenia, thrombocytopenia.
    • Microangiopathic haemolytic anaemia, and thrombocytopenia (sometimes in combination) in severely immunocompromised adults, particularly those with advanced HIV disease, receiving high doses (8000 mg daily) of valaciclovir for prolonged periods in clinical trials. These findings have also been observed in people not treated with valaciclovir who have the same underlying or concurrent conditions.

[BNF, 2024; EMC, 2024a]

Drug interactions

  • Nephrotoxic drugs (for example, gentamicin, tacrolimus, methotrexate, voclosporin) — additive nephrotoxicity if valaciclovir is taken concurrently. Monitor renal function closely, particularly in people with renal impairment. 
    • Ciclosporin — cases of nephrotoxicity and increased concentrations of ciclosporin have been reported with aciclovir and similar effects are expected with valaciclovir.  
  • Live herpes-zoster vaccine — vaccine efficacy may be affected. Avoid live herpes-zoster vaccines until at least 48 hours after stopping valaciclovir. If possible, avoid valaciclovir for 2 weeks after live herpes-zoster vaccines. 

[Preston, 2024]

Shingrix

Dose

  • Give two doses of 0.5 mL a minimum of 8 weeks apart.
    • Shingrix® should be given by intramuscular injection, preferably in the deltoid region of the upper arm.
  • In the UK vaccination program, the second dose is given after an interval of 6-12 months in immunocompetent people, and after 8 weeks to 6 months in people who are immunosuppressed.

[UKHSA, 2023; UKHSA, 2024] 

Contraindications and cautions

  • There are no known contraindications (other than known hypersensitivity to any of the ingredients). However, the UKHSA advises that vaccination may be postponed if the person has an acute illness. 
    • This is not necessary in people with a minor illness without fever or systemic upset.

[BNF, 2024; EMC, 2024b]

Adverse effects

  • Common adverse effects include:
    • Fatigue.
    • Headache
    • Injection site pain.
    • Myalgia.
  • Most of these lasted less than 3 days.
  • There have been reports of an increased risk of Guillain-Barre syndrome (estimated as 3 excess cases per million doses).

[BNF, 2024; EMC, 2024b]

Drug interactions

  • The manufacturer advises that concomitant use with other vaccines is not recommended, with the exception of:
    • Unadjuvanted inactivated seasonal influenza vaccine.
    • PPV23 vaccine.
    • PCV12 vaccine.
    • Monovalent COVID-19 mRNA booster vaccine.
    • Diphtheria-tetanus-acellular pertussis vaccine (dTpa). 

[EMC, 2024b]

Supporting evidence

This CKS topic is largely based on the chapter on Shingles (herpes zoster) in Immunisation against infectious disease (the 'Green book') [UKHSA, 2024], a German consensus guideline S2k guidelines for the diagnosis and treatment of herpes zoster and postherpetic neuralgia [Gross, 2020], the BMJ Best Practice guide Herpes zoster [BMJ Best Practice, 2024a], and expert opinion in a narrative review Recommendations for the management of herpes zoster [Dworkin, 2007]. The rationales for individual recommendations is discussed in the relevant basis for recommendation sections of the topic.

How this topic was developed

This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website.

Search strategy

A literature search was conducted for guidelines and systematic reviews on primary care management of shingles.

Search dates

August 2019 - June 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 29th August 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S4    S1 OR S2 OR S3 
S3    AB shingles OR TI shingles 
S2    AB herpes zoster OR TI herpes zoster 
S1    (MH "Herpes Zoster+") 

Sources of guidelines

Sources of systematic reviews and meta-analyses

  • The Cochrane Library:
    • Systematic reviews
    • Protocols
    • Database of Abstracts of Reviews of Effects
  • Medline (with systematic review filter)
  • EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

Sources of randomized controlled trials

  • The Cochrane Library:
    • Central Register of Controlled Trials
  • Medline (with randomized controlled trial filter)
  • EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

Sources of national policy

Patient experiences

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

  • Clinical accuracy.
  • Consistency with other providers of clinical knowledge for primary care.
  • Accuracy of implementation of national guidance (in particular NICE guidelines).
  • Usability.

Principles of the consultation process

  • The process is inclusive and any individual may participate.
  • To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
  • Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
  • Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
  • External reviewers are not paid for commenting on the draft topics.
  • Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
  • All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
  • All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

  • Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
  • Stakeholders identified from the following groups are invited to review draft topics:
    • Experts in the topic area.
    • Professional organizations and societies (for example, Royal Colleges).
    • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
    • Guideline development groups where the topic is an implementation of a guideline.
    • The British National Formulary team.
    • The editorial team that develop MeReC Publications.
  • Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

  • Topic selection
  • Scoping of topic
  • Selection of clinical scenarios
  • First draft internal review
  • Second draft internal review
  • External review
  • Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

  • Animal studies
  • Original research is not written in English

Possible exclusions for reviewed literature:

  • Sample size too small or study underpowered
  • Bias evident or promotional literature
  • Population not relevant
  • Intervention/treatment not relevant
  • Outcomes not relevant
  • Outcomes have no clear evidence of clinical effectiveness
  • Setting not relevant
  • Not relevant to UK
  • Incorrect study type
  • Review article
  • Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

  • Feasibility
    • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
  • Organizational and Financial Impact Analysis
  • Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
    • Eligible population
    • Current interventions
    • Likely uptake of new intervention or recommendation
    • Cost of the current or new intervention mix
    • Impact on other costs
    • Condition-related costs
    • In-direct costs and service impacts
    • Time dependencies
  • Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

  • Personal financial interests
  • Personal family interest
  • Personal non-financial interest
  • Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.

References

  • Andrews, N., Stowe, J., Kuyumdzhieva, G., et al. (2020) Impact of the herpes zoster vaccination programme on hospitalised and general practice consulted herpes zoster in the 5 years after its introduction in England: a population-based study. BMJ Open 10(7), e037458. [Abstract] [Free Full-text]
  • BAD (2020) Shingles (herpes zoster infection). British Association of Dermatology. [Free Full-text]
  • BMJ Best Practice (2024a) Herpes zoster infection. BMJ Publishing Group. https://bestpractice.bmj.com
  • BMJ Best Practice (2024b) Acute varicella-zoster. BMJ Publishing Group. https://bestpractice.bmj.com
  • BNF (2024) British National Formulary. National Institute for Health and Care Excellence. https://bnf.nice.org.uk
  • CDC (2024) Shingles (herpes zoster). U.S. Centers for Disease Control and Prevention. [Free Full-text]
  • Cohen, K.R., Salbu, R.L., Frank, J. and Israel, I. (2013) Presentation and management of herpes zoster (shingles) in the geriatric population. Pharmacy and Therapeutics 38(4), 217-224. [Free Full-text]
  • de Oliveira Gomes, J. Gagliardi, A.M.Z., Andriolo, B.N.G., Torloni, M.R., et al. (2023) Vaccines for preventing herpes zoster in older adults (Cochrane review). Issue 10. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Dworkin, R.H., Johnson, R.W., Breuer, J., et al. (2007) Recommendations for the management of herpes zoster. Clinical Infectious Diseases 44(Suppl 1), S1-S26. [Abstract]
  • EMC (2023a) SPC for Aciclovir 400 mg Tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2023b) SPC for Famciclovir 500mg film-coated tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2024a) SPC for Valaciclovir 500 mg Film Coated Tablets. Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • EMC (2024b) SPC for Shingrix powder and suspension for suspension for injection, Herpes zoster vaccine (recombinant, adjuvanted). Electronic Medicines Compendium. Datapharm Communications Ltd. https://www.medicines.org.uk/emc [Free Full-text]
  • Forbes, H., Bhaskaran, K., Thomas, S., et al. (2014) Quantification of risk factors for herpes zoster: population based case-control study. BMJ 348(g2911). [Abstract]
  • Gross, G.E., Eisert, L., Doerr, H.W., et al. (2020) S2k guidelines for the diagnosis and treatment of herpes zoster and postherpetic neuralgia. Journal of the German Society of Dermatology 18(1), 55-78. [Abstract]
  • Jiang, X., Li, Y., Chen, N., et al. (2023) Corticosteroids for preventing postherpetic neuralgia (Cochrane review). Issue 12. John Wiley & Sons, Ltd. http://www.cochranelibrary.com [Free Full-text]
  • Johnson, R., Alvaerz-Pasquin, M., Bijl, M., et al. (2015) Herpes zoster epidemiology, management, and disease and economic burden in Europe: a multidisciplinary perspective. Therapeutic Advances in Vaccines 3(4), 109-120. [Abstract]
  • Kawai, K. and Yawn, B.P. (2017) Risk factors for herpes zoster: a systematic review and meta-analysis. Mayo Clinic Proceedings 92(12), 1806-1821. [Abstract]
  • Le, P. and Rothberg, M. (2019) Herpes zoster infection. BMJ 364, k5095. [Abstract]
  • McDonald, E.M., de Kock, J. and Ram, F.S. (2012) Antivirals for management of herpes zoster including ophthalmicus: a systematic review of high-quality randomized controlled trials. Antiviral Therapy 17(2), 255-264. [Abstract]
  • Mikaeloff, Y., Kezouh, A. and Suissa, S. (2007) Nonsteroidal anti-inflammatory drug use and the risk of severe skin and soft tissue complications in patients with varicella or zoster disease. British Journal of Clinical Pharmacology 65(2), 203-209. [Abstract]
  • Muñoz-Quiles, C., López-Lacort, M., Díez-Domingo, J. and Orrico-Sanchez, A. (2020) Herpes zoster risk and burden of disease in immunocompromised populations: a population-based study using health system integrated databases, 2009–2014. BMC Infectious Diseases 20(1), 905. [Abstract]
  • NHS England (2023) General practice shingles vaccination programme technical guidance. NHS England. [Free Full-text]
  • NHS England (2025) Quality and Outcomes Framework guidance for 2025/26. NHS England. https://www.england.nhs.uk [Free Full-text]
  • NHS Inform (2023) Shingles. [Free Full-text]
  • NHS (2023) Shingles. [Free Full-text]
  • NICE (2020) Neuropathic pain in adults: pharmacological management in non-specialist settings. National Institute for Health and Care Excellence. http://www.nice.org.uk [Free Full-text]
  • Preston, C.L (2024) Stockley's Drug Interactions. Medicines Complete. Pharmaceutical Press. https://www.medicinescomplete.com
  • Qian, J., Macartney, K., Heywood, A.E., et al. (2021) Risk of recurrent herpes zoster in a population-based cohort study of older adults. Journal of the American Academy of Dermatology 85(3), 611-618. [Abstract]
  • Saguil, A., Kane, S. and Mercado, M. (2017) Herpes zoster and postherpetic neuralgia: prevention and management. American Family Physician 96(10), 656-663. [Free Full-text]
  • Schmader, K. (2016) Herpes zoster. Clinics in geriatric medicine 32(3), 539-553. [Abstract]
  • Steinmann, M., Lampe, D., Grosser, J., et al. (2024) Risk factors for herpes zoster infections: a systematic review and meta‑analysis unveiling common trends and heterogeneity patterns. Infection 52(3), 1009-1026. [Abstract]
  • Ting, D.S.J., Ghosh, N. and Ghosh, S. (2019) Herpes zoster ophthalmicus. BMJ 364, k5234. [Abstract]
  • UKHSA (2023) Shingles immunisation programme: information for healthcare practitioners. UK Health Security Agency. https://www.gov.uk [Free Full-text]
  • UKHSA (2024) Shingles: the green book chapter 28a. UK Health Security Agency. https://www.gov.uk [Free Full-text]
  • Yanni, E.A., Ferreira, G., Guennec, M., et al. (2018) Burden of herpes zoster in 16 selected immunocompromised populations in England: a cohort study in the Clinical Practice Research Datalink 2000-2012. BMJ Open 8(6), e020528. [Free Full-text]
  • Zorzoli, E., Pica, F., Masetti, G. Franco, E., et al. (2018) Herpes zoster in frail elderly patients: prevalence, impact, management, and preventive strategies. Aging Clinical and Experimental Research 30(7), 693-702. [Abstract]
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