How to manage shingles

Herpes zoster, commonly known as shingles, is a common viral infection caused by reactivation of the varicella-zoster virus (VZV). GPs are usually the first point of contact and play a central role in shingles diagnosis, early management, patient education, and prevention of complications.

How to identify and diagnose shingles

The typical clinical presentation of shingles includes prodrome and rash. Prodrome precedes the rash by one to three day and it is characterised by pain, burning, or tingling localized to a dermatome affected by the virus.

The characteristic shingles rash presents as erythematous maculopapular lesions that evolve into grouped vesicles. These are typically unilateral and also confined to a single dermatome.

The common sites include:

• Thoracic (most common),
• Cranial (notably ophthalmic branch of CN V),
• Lumbar, and
• Cervical dermatomes.

Shingles can also have atypical presentations, such as:

• Zoster sine herpete (pain without rash)
• Disseminated zoster (in immunocompromised patients, involving multiple dermatomes or systemic involvement)

Clinical diagnosis of shingles is usually sufficient. Although, primary care physicians can sometimes consider PCR testing of lesion swabs (if diagnosis is unclear or in immunocompromised patients).

Initial management of shingles

Management of shingles in primary care may include antiviral therapy, pain management, and topical care.

Antiviral therapy provides best outcomes when it is initiated, ideally, within 72 hours of rash onset. Commonly used medications include:

• Acyclovir 800 mg five times daily for 7 days
• Valacyclovir 1,000 mg three times daily for 7 days
• Famciclovir 500 mg three times daily for 7 days

*Valacyclovir or famciclovir are preferred for better bioavailability and simpler dosing.

For the management of mild to moderate pain, NSAIDs or paracetamol are usually sufficient. Severe pain and neuropathic feature may require:

• Gabapentin or pregabalin
• Tricyclic antidepressants (e.g., amitriptyline)
• Short course of opioids in select cases

Topical care usually includes keeping the lesions clean and dry. Calamine lotion or cool compresses may provide relief.

Referral and red flags

If the ophthalmic branch is affected (forehead, tip of nose – Hutchinson’s sign) or there are visual symptoms, such as pain, photophobia, or decreased vision, urgent referral to ophthalmology is advised.

Additionally, GPs can refer or consider hospital admission for:

• Disseminated zoster or systemic symptoms in immunocompromised patients
• Neurological complications (meningitis, encephalitis, motor neuropathy)
• Inadequate pain control despite oral analgesia

Complications to monitor

The potential shingles complications to monitor include:

• Postherpetic neuralgia (PHN) – Persistent pain >90 days after rash onset; most common complication, particularly in older adults.
• Secondary bacterial infection – Especially if vesicles rupture or are excoriated.
• Neurological sequelae – Including cranial nerve palsies, myelitis, and encephalitis.
• Ocular involvement – Risk of keratitis, uveitis, and vision loss.

Prevention and vaccination

Shingles vaccination reduces the risk of shingles and PHN.

Recombinant zoster vaccine (RZV, Shingrix) is preferred: Two doses, 2–6 months apart are recommended for adults ≥50 years and immunocompromised patients ≥18 years.

Live zoster vaccine (Zostavax) may be used if RZV unavailable, but it is less effective.

Effective management of shingles in primary care involves timely diagnosis, prompt antiviral therapy, tailored pain management, and vigilant monitoring for complications. Vaccination remains a key preventive strategy. With a structured approach, GPs can significantly reduce the morbidity associated with shingles and its complications.

 – Dr Rosmy De Barros

Next steps in your learning journey

🎓 Certificate Courses in General Dermatology

Our university-assured, structured pathway to elevate your knowledge in GP dermatology. ➡️ Explore full program >

🎓 Micro-Courses in General Dermatology

Explore short, bite-sized CPD modules in focused topics in dermatology. Complete in less than 10 hours! ➡️ Browse Micro-Courses >

🎓 HealthCert 365 subscription

Prefer flexible learning across many topics? Access 4,000+ CPD hours on-demand with HealthCert 365 — an annual subscription for one flat fee. ➡️ Discover HealthCert 365 >

Explore more free educational content in General Dermatology >

CPD self-submission

You can self-record this blog for CPD. Quick Log CPD hours with the RACGP/ACRRM via the usual self-submission process. You will be asked to reflect on what you have learned, and you will require supporting evidence such as a screenshot. For more information, view the: RACGP CPD guide | ACRRM CPD guide

References

• Wilson, M., Wilson, P. J., Wilson, M., & Wilson, P. J. (2021). Shingles. Close Encounters of the Microbial Kind: Everything You Need to Know About Common Infections, 137-145.
• Wilms, L., Weßollek, K., Peeters, T. B., & Yazdi, A. S. (2022). Infections with Herpes simplex and Varicella zoster virus. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 20(10), 1327-1351.
• Yakovenko, V., Ciobotaro, P., Bardenstein, R., Zusev, M., & Zimhony, O. (2024). The Role of Varicella Zoster Virus (VZV) in Central Nervous System Infectious Syndromes. Canadian Journal of Infectious Diseases and Medical Microbiology, 2024(1), 6664417.
• Krulikowski, K., Shectman, B., Ilyas, D., & Riskin, S. I. (2025). Exploring Risk Factors and Patterns in Uncommon Recurrences of Varicella-Zoster Reactivation: A Review of Case Reports. Cureus, 17(5).
• Kelley, A. (2022). Herpes zoster: A primary care approach to diagnosis and treatment. JAAPA, 35(12), 13-18.
• Pupic–Bakrač, A., Pupić–Bakrač, J., Gabrić, I., Vukojević, N., & Jukić, T. (2022). Herpes Zoster Opthalmicus–Related Ophthalmoplegia: Anatomical, Pathogenetic, and Therapeutic Perspectives. Journal of Craniofacial Surgery, 33(8), 2463-2467.
• Lim, D. Z. J., Tey, H. L., Salada, B. M. A., Oon, J. E. L., Seah, E. J. D., Chandran, N. S., & Pan, J. Y. (2024). Herpes Zoster and Post-Herpetic Neuralgia—Diagnosis, Treatment, and Vaccination Strategies. Pathogens, 13(7), 596.