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Shingles - Management
Basis for recommendation

  • This recommendation is based on guidelines for the management of shingles from the British Society for the Study of Infection [BSSI, 1995], guidelines on the management of herpes zoster in the immunocompetent host from the International Herpes Management Forum [International Herpes Management Forum, 2002], recommendations for the management of herpes zoster from an internationally representative panel [Dworkin et al, 2007], and the following evidence.
  • Benefits and harms of antiviral drugs
    • Evidence indicates that antiviral drugs reduce the severity and duration of shingles and are generally well tolerated. Some evidence also indicates that the use of antivirals can help prevent post-herpetic neuralgia, but this is less conclusive [BSSI, 1995; Volpi et al, 2005; Tyring, 2007].
    • For people who are at low risk of complications (e.g. young people, and those with mild pain and rash, or truncal involvement), the potential benefits of antiviral treatment are unknown, but it may reduce the risk of post-herpetic neuralgia. The safety of the antivirals also provides a favourable benefit-to-risk ratio [Dworkin et al, 2007].
      • A systematic review of the primary care management of acute herpes zoster [Lancaster et al, 1995] found that the most common adverse events with aciclovir were headache and nausea (no major adverse events were reported). In the control groups, the incidence of adverse effects was similar.
    • Aciclovir resistance is very rare in immunocompetent people [Ahmed et al, 2007].
  • Timing of treatment
    • Evidence suggests little difference in resolution of zoster-associated pain when antiviral therapy is initiated before 48 hours compared with 48–72 hours after rash onset [Wood et al, 1998].
    • Evidence is lacking for the benefit of delayed initiation of antiviral treatment, but observational data from two uncontrolled studies found no significant difference in the persistence of pain between people starting treatment within 72 hours and those starting treatment after 72 hours. The authors of review articles discussing this concluded that, although evidence is not conclusive, there may be a benefit from starting antiviral treatment 72 hours or more after rash onset [Christo et al, 2007; Dworkin et al, 2007; Tyring, 2007]. Recommendations from an international panel of experts advise consideration of prescribing after 72 hours if the person is older or has severe pain, as these are strong risk factors for post-herpetic neuralgia [Dworkin et al, 2007]. CKS has based its recommendations on this evidence and feedback from expert reviewers.
  • Pregnant women
    • Herpes zoster is not a risk to the fetus [Pass et al, 1999]. Expert feedback suggests this is because of pre-existing varicella antibodies. CKS recommends seeking specialist advice for pregnant women with shingles because the safety of antiviral treatment in pregnancy has not been firmly established; therefore, pregnant women should only be treated if the potential benefits of treatment outweigh the risk to the fetus. Most pregnant women are thought to be at lower risk of post-herpetic neuralgia because of their relatively younger age [Dworkin et al, 2007].
  • Immunocompromised people
    • CKS recommends treating immunocompromised people with oral antivirals only if the rash is localized and not severe, as immunocompromised people are more at risk of complications (e.g. cutaneous dissemination, visceral dissemination, and multidermatomal involvement with deep-tissue destruction) [BSSI, 1995; International Herpes Management Forum, 2002; Tyring, 2007].
    • CKS recommends seeking specialist advice for if the person is systemically unwell, has severe shingles, or is severely immunocompromised, because in this group, there is a higher risk of disseminated disease and complications [Dworkin et al, 2007]. Resistance to antiviral treatment can also be a problem [Ahmed et al, 2007].
  • Children
    • CKS has not recommended antiviral treatment for otherwise healthy children, because in this group shingles is usually mild and post-herpetic neuralgia is rare [Feder and Hoss, 2004]. In addition, aciclovir, valaciclovir, and famciclovir are not licensed for this purpose in children [BNF for Children, 2007; BNF 55, 2008].

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