QuestionSBA
QuestionChoice
Cannabis sativa extract should not be prescribed in a non-specialist setting
32812
e
Cannabis sativa extract
QuestionChoice
Tramadol should only be considered in cases where acute relief is needed. Therefore, it would not be appropriate in this case at this time
32810
c
Tramadol
QuestionChoice
Post-herpetic neuralgia is treated as a type of neuropathic pain. Therefore, the first-line medication can be either amitriptyline, duloxetine, gabapentin or pregabalin
32808
a
Amitriptyline
QuestionChoice
Capsaicin cream should be offered only if oral medication is inappropriate
32811
d
Capsaicin cream
QuestionChoice
Non-steroidal anti-inflammatory drugs are not recommended in post-herpetic neuralgia as there is no evidence to support their use
32809
b
Ibuprofen
QuestionComment
Give them the loud pack rt 
28324
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subscriber
Odor Womb
Concept
Chapter
# Summary 

Shingles is a reactivation of the varicella zoster virus which can lie dormant in nerve ganglia following primary infection (chickenpox). It commonly occurs in the elderly and shingles in young adults should prompt investigation for an underlying immune condition. Management normally includes oral antivirals, but intravenous antiviral medications can be used if severe or if the patient is immunocompromised.

# Signs & Symptoms

Shingles can manifest first as a tingling feeling in a dermatomal distribution. Progresses to erythematous papules occurring along one or more dermatomes within a few days, which develop into fluid-filled vesicles which then crust over and heal. May be associated with viral symptoms e.g. fever, headache, malaise.

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**Herpes zoster ophthalmicus (HZO)** presents with symptoms including a painful red eye, fever, malaise, and headache, followed by an erythematous vesicular rash over the trigeminal division of the ophthalmic nerve. A lesion on the nose, known as **Hutchinson's sign,** may suggest ocular involvement.



# Management

- Oral antiviral (e.g. valaciclovir 1g three times per day for 7 days) within 72h of rash onset if immunocompromised (and infection is not severe) or moderate/severe rash or moderate/severe pain, or non-truncal involvement.
- Admit to hospital for IV antivirals if severe disease or immunocompromise, ophthalmic symptoms or suspicion of meningitis/encaphalitis/myelitis
- Advise avoiding contact with pregnant women, babies and those who are immunocompromised until the lesions are fully crusted over, as transmission can occur via skin contact
- Pain can be managed with NSAIDs (e.g. ibuprofen). If unsuccessful, consider offering amitriptyline (off-label use), duloxetine (off-label use), gabapentin, or pregabalin

# Shingles vaccine

There is a one-off vaccine available for shingles that is typically advised for those in their 70s.

# Complications

- Secondary bacterial infection of skin lesions
- Corneal ulcers, scarring and blindness if eye involved
- Post-herpetic neuralgia
  - Pain occurring at site of healed shingles infection
  - Can cause neuropathic type pain (burning, pins and needles)
  - Can cause allodynia (perception of pain from a normally non-painful stimulus e.g. light touch)

# NICE Guidelines

[NICE Clinical Knowledge Summary (CKS): Shingles](https://cks.nice.org.uk/topics/shingles/)

[NICE Treatment Summary: Varicella-zoster vaccine](https://bnf.nice.org.uk/treatment-summary/varicella-zoster-vaccine-2.html)
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Another example of the appearance of a shingles rash, this time situated on the chest
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Dermatology
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An example of the typical appearance of a shingles rash
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Dermatology
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Shingles
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Dermatology
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Post-herpetic neuralgia is a type of neuropathic pain often treated with amitriptyline as a first-line pharmacological option.
A 57-year-old woman attends GP due to moderate pain. The pain is localised over the same area of skin where she had shingles three months ago. She now experiences pain whenever that area becomes cold or whenever it is touched lightly.

The GP diagnoses post-herpetic neuralgia and advises the patient to wear cotton clothes over the affected area; to wrap the area in clingfilm, and advised her how to improve her sleep.

What pharmacological treatment could also be considered in the first instance?
a