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Shingles - Management
Basis for recommendation

  • CKS could find no specific UK guidelines on the referral of people with shingles and therefore has made general recommendations on the basis of the opinion of an international panel [Dworkin et al, 2007] and a US expert [Weinberg, 2007].
  • In cases of ophthalmic shingles, the recommendations are based on those in a US article [Gnann, 2006] and a review on managing ophthalmic shingles in primary care [Opstelen and Zaal, 2005].
  • In pregnancy, the safety of antiviral treatment is not firmly established [Dworkin et al, 2007].
  • CKS has recommended seeking specialist advice for severely immunocompromised people, or immunocompromised people with a widespread rash or who are systemically unwell, regarding choice, route, and duration of antiviral drug therapy. These people are at higher risk of disseminated disease and complications, and may need intravenous antiviral treatment [BSSI, 1995; Ahmed et al, 2007; Dworkin et al, 2007]. Resistance to antiviral treatment can also be a major problem in immunocompromised people [Ahmed et al, 2007].
  • CKS has recommended referral of a person with a reactivation of shingles, as it is atypical to see reactivations in younger people with no history of malignancy and no immune deficit [Rashid et al, 2007], and therefore underlying immunocompromise may need to be excluded.
  • CKS recommends seeking specialist advice for recurrent shingles in immunocompromised people. Shingles typically recurs once prophylaxis is stopped in immunocompromised people, and recurrences are more likely to be associated with aciclovir-resistant strains [Ahmed et al, 2007]. There is indirect evidence from randomized placebo-controlled trials that long-term aciclovir substantially reduces the risk of herpes zoster in people receiving a bone marrow transplant [Prentice and Hann, 1983; Lundgren et al, 1985; Perren et al, 1988], and from an observational study that treatment with aciclovir, valaciclovir, or famciclovir prevents herpes zoster in people given immunosuppressive therapy for multiple myeloma [Vickrey et al, 2009].

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