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SHINGLES (Management (Information & advice ((Explain that only a…
SHINGLES
Management
Prevention -
Shingles vaccine should be offered to Pt between 70 -79
Information & advice
Explain that only a person who has not had chickenpox or the varicella vaccine can catch chickenpox from a person with shingles. The person with shingles is infectious until all the vesicles have crusted over (usually 5-7 days after rash onset).
Advise people with shingles to:
Avoid contact with people who have not had chickenpox, particularly pregnant women, immunocompromised people, and babies younger than 1 month of age.
Avoid sharing clothes and towels.
Wear loose-fitting clothes to reduce irritation.
Cover lesions that are not under clothes while the rash is still weeping.
Avoid use of topical creams and adhesive dressings, as they can cause irritation and delay rash healing.
Keep the rash clean and dry to reduce the risk of bacterial superinfection. Seek medical advice if there is an increase in temperature, as this may indicate bacterial infection.
Avoid work, school, or day care if the rash is weeping and cannot be covered. If the lesions have dried or the rash is covered, avoidance of these activities is not necessary.
Medication
If specialist advice or referral is not required, start oral aciclovir, valaciclovir, or famciclovir (use clinical judgement, taking into account cost and compliance issues for each individual) within 72 hours of rash onset for:
Anyone aged 50 years and over.
People aged less than 50 years with any of the following criteria:
Immunocompromised (if the level of immunocompromise is not severe, the rash is localized, the person is not systemically unwell, and they can be closely followed up).
Non-truncal involvement (such as shingles affecting the neck, limbs, or perineum).
Moderate or severe pain.
Moderate or severe rash
Pain managment
Adults - paracetamol or in combination with codeine. If not effective consider amitriptyline, duloxetine, gabapentin or pregabalin.
Consider oral corticosteroids in the first 2 weeks following rash onset in immunocompetent adults with localised shingles if pain is severe, but only in combination with antiviral medication. Use clinical judgment, taking into account the risks and benefits of corticosteroid therapy for each person.
Diagnosis
Diagnose shingles on the basis of typical clinical features, which include:
Healing (2–4 weeks) — the lesions usually crust over within 7–10 days.
Investigations are not usually required in primary care. If there is diagnostic uncertainty, refer or seek specialist advice
Rash usually unilateral.Macules & papules develop into vesicular lesions in a dermatomal distribution. The location depends on which nerve is involved,but shingles usually occurs on the thorax, with dermatomes T1 to L2 most commonly affected. The vesicles then burst realising varicella-zoster virus & form ulcers & crusts.
Prodrome (several days before the rash) — abnormal sensation (for example burning, tingling, or itch) in the affected skin. The prodrome may also include headache, malaise, and occasionally fever
Pain — varicella-zoster virus induced neuritis may cause intense neuralgic pain over the affected area, especially in people with trigeminal nerve involvement. The pain can be described as burning, aching, or stabbing. There may also be itch, numbness, or prickling or tingling sensations. Pain can be intermittent or constant and may be so severe it interferes with sleep.
Differenital diagnosis
The most common differential diagnosis for shingles is herpes simplex virus (HSV) infection. This can also present with a unilateral, red, maculopapular, vesicular rash and acute pain.
Features which are more likely to indicate HSV infection include multiple recurrences (around the mouth or genital areas) and lack of chronic pain.
Other skin conditions which can look similar to shingles are contact dermatitis, burns, and fungal infections.
The prodromal pain of shingles can often mimic other conditions, depending on the site of infection, for example migraine, trigeminal neuralgia, myocardial infarction, acute appendicitis, renal calculi, and cholecystitis.
Specialist advice
Seek immediate specialist advice regarding antiviral treatment for people with ophthalmic involvement; severely immunocompromised people; immunocompromised people who are systemically unwell, or have a severe or widespread rash or multiple dermatomal involvement; immunocompromised children; or pregnant or breastfeeding women.
Seek specialist advice if pain not controlled and patient requires morphine.
Definition
Shingles (herpes zoster) is a viral infection of nerve cells [PHE, 2016] that occurs when a latent infection with varicella-zoster virus reactivates because of a decrease in virus-specific cell-mediated immunity.This can be many years after the primary infection. It is characterized by pain in a dermatomal distribution and a localised vesicular rash.
Shingles and chickenpox are both caused by the varicella-zoster virus, but chickenpox usually causes a widespread rash and follows initial infection.