guidelines

shingles (herpes zoster)

nice cks: who benefits from antivirals, aciclovir/valaciclovir regimens, ophthalmic red flags, and post-herpetic neuralgia prevention/management.

last reviewed: 2026-02-13
based on: NICE CKS: Shingles + BNF antiviral dosing checks (accessed Feb 2026)
reviewer: Dr Kola Tytler MBBS CertHE MBA MRCGP
view official NICE source

Executive summary

  • Diagnosis: unilateral dermatomal pain → vesicular rash (often preceded by neuropathic pain).
  • Antivirals: most effective when started within 72 hours of rash onset; consider later if new lesions are appearing or in high-risk groups.
  • Ophthalmic shingles is urgent: eye symptoms, visual change, or Hutchinson’s sign (tip of nose) → same-day ophthalmology.
  • Pain matters: treat early and proactively; consider neuropathic agents for post-herpetic neuralgia (PHN).

Antiviral regimens (adult typical dosing; check renal function)

  • Aciclovir: 800 mg five times daily for 7 days.
  • Valaciclovir: 1 g TDS for 7 days.

Eligibility (CKS-style): treat early in older adults and those at higher risk (immunosuppression, severe pain, severe rash, ophthalmic involvement, or complications). Dose-adjust in renal impairment.

Red flags / urgent pathways

  • Ophthalmic involvement: red eye, photophobia, visual change, rash near eye, Hutchinson’s sign → same-day ophthalmology.
  • Immunocompromised with extensive rash/systemic symptoms → urgent specialist assessment (risk of dissemination).
  • Neurological complications: facial palsy, meningism, limb weakness → urgent assessment.

Transparency

This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.