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    Shingles –
    Shingles occurs when the varicella-zoster virus (which causes chickenpox) is reactivated from latency in the central nervous system.

    Complications include post-herpetic neuralgia, secondary infection, scarring, and ocular complications.
    Unlike chickenpox, shingles can only be transmitted by direct skin contact with the affected area.

    Only a person who has not had chickenpox or the varicella vaccine can ‘catch’ chickenpox from a person with shingles.

    Diagnosis is usually made on clinical grounds as shingles occurs in 3 phases:

    Prodrome (1–4 days before the rash) — fever and myalgia, with burning, tingling, numbness, or pruritus in the affected skin.

    Acute (painful rash lasting 7–10 days) — macules and papules develop into vesicular lesions in a dermatomal distribution (commonly on the thorax), then burst, releasing varicella-zoster virus.

    Healing (2–4 weeks) — the lesions crust over.

    A person with shingles should be advised to:

    Avoid direct skin contact (involving the affected area) with pregnant women (if they cannot recall having had chickenpox), immunocompromised people, and babies younger than 1 month of age (unless it is their own baby, who will have maternally-derived antibodies against the virus).

    Keep the rash clean and dry to reduce the risk of infection.

    Avoid use of topical antibiotics and adhesive dressings, as they can cause irritation and delay healing.

    Seek medical advice if they have a fever, as this may indicate bacterial infection.

    Avoid work, school, or day care if the rash is weeping and cannot be covered. This is unnecessary if the lesions have dried or the rash is covered.

    To manage associated pain in adults, paracetamol alone or in combination with codeine or ibuprofen should be offered.
    In severe pain, amitriptyline (off-label use) or pregabalin (or gabapentin) should be considered. Oral imipramine or nortriptyline may be considered as an alternative to amitriptyline (off-label use).

    To manage severe pain, oral corticosteroids may be considered in the first 2 weeks following rash onset in immunocompetent adults (excluding certain groups, such as people with insulin dependent diabetes mellitus) with localized shingles, but only in combination with antiviral medication, and based on clinical judgment, taking into account the risks and benefits of corticosteroid therapy for each person.

    To manage associated pain in children, paracetamol or ibuprofen should be offered. If these are not effective, specialist advice should be sought.

    An oral antiviral drug (such as aciclovir) should be started within 72 hours of rash onset for a certain group of people, such as people aged 50 years or older, people with non-truncal involvement (e.g. shingles affecting the neck, limbs, or perineum), and people with moderate or severe pain or rash.

    If it is not possible to initiate treatment within 72 hours, antiviral treatment can be considered up to 1 week after rash onset, especially if the person is at higher risk of severe shingles or complications (e.g. continued vesicle formation, older age, immunocompromised, or severe pain).

    For pregnant women, specialist advice should be sought regarding prescribing antiviral treatment.

    For immunocompetent children with shingles, antiviral treatment is not recommended.

    In all people with shingles, clinical judgment should be used to decide who to refer, who to refer to, and the urgency of the referral.
    For example:
    Urgent admission or specialist advice may be necessary if the person has a complication, is severely immunocompromised, or pregnant.

    Less urgent referral may be necessary if new vesicles are forming after 7 days of antiviral treatment, healing is delayed, or if pain is inadequately controlled by oral analgesia.

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