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Overview
Consider calculating NEWS2 Score ahead of signposting patient to A&E or calling 999 in a life threatening emergency
Consider calculating NEWS2 Score ahea...
Does the patient have shingles up to one week after rash onset?
Does the patient have shingles up t...
Serious complications suspected
  • Meningitis (neck stiffness, photophobia, mottled skin)
  • Encephalitis (disorientation,changes in behaviour)
  • Myelitis (muscle weakness, loss of bladder or bowel control)
  • Facial nerve paralysis (typically unilateral) (Ramsay Hunt)
Serious complications suspected...
Patient presents with signs and symptoms of shingles
Patient presents with signs and symptoms of shingles
NHSE PATHWAYS
NHSE PATHWAYS
Consider the risk of deterioration, red flags or IF ANY of the serious complications are suspected
Consider the risk of deterioration, red flags or IF ANY of the seriou...
YES
YES
NO
NO
NICE CKS
NICE CKS
NHSE PGDs
NHSE PGDs
Gateway Point
Gateway Point
Does the patient follow typical progression of shingles clinical features (To be used as a guide to support diagnosis - not all below may be present):
Does the patient follow typical progression of shingles clinical features (To be used as a guide to support diagnosis - not all below m...
Shingles (for adults aged 18 years and over)
Shingles Context: UK Pharmacy First Sche...View PGD in right panelView PGD in right panel
Digital PGD
 Digital PGD
Exclude: pregnant individuals
Exclude: pregnant individuals
Gateway Point
Gateway Point
  • First signs of shingles are an abnormal skin sensation and pain in the affected area which can be described as burning, stabbing, throbbing, itching, tingling and can be intermittent or constant.
  • The rash usually appears within 2-3 days after the onset of pain, and a fever and or a headache may develop.
  • Shingles rash appears as a group of red spots on a pink-red background which quickly turn into small fluid-filled blisters.
  • Some of the blisters burst, others fill with blood or pus. The area then slowly dries, crusts and scabs form.
  • Shingles rash usually covers an area of skin on one side of the body.
  • Refer to NHS.UK website for images of Shingles
First signs of shingles are an abnormal skin sensation and pain in the affected area which can be described as burning, stabbing...
Does the patient have shingles within 72 hours of rash onset?
Does the patient have shingles within 72 hours...
Consider alternative diagnosis
and proceed appropriately
Consider alternative diagnosis...
YES
YES
NO
NO
Shingles less likely
Shingles less likely
Shingles more likely
Shingles more likely
FOR ALL PATIENTS:
  • If symptoms worsen rapidly or significantly at any time, OR do not improve after completion of treatment course
  • Share self-care and safety-netting advice using British Association of Dermatologists Shingles leaflet
  • For pain management recommend a trial of paracetamol, a NSAID such as ibuprofen, or co-codamol over the counter. If this is not effective, refer patient to general practice
  • Signpost eligible individuals to information and advice about receiving the shingles vaccine after they have recovered from this episode of shingles
FOR ALL PATIENTS:...

Content sourced and adapted from NHS Pharmacy First – Clinical Pathways and Patient Group Directions (PGDs) on the NHS England website, licensed under the Open Government Licence v3.0.

Content sourced and adapted from NHS Pharmacy First – Clinical Pathways and Patient Group Directions (PGDs) on the NHS England website, licensed under the Open Government Licence v3.0.
  • General practice
  • Other provider as appropriate
General practice Other...Onward referral
Shingles in the ophthalmic distribution
  • Hutchinson's sign — a rash on the tip, side, or root of the nose
  • Visual symptoms
  • Unexplained red eye
Shingles in the ophthalmic distribution...
  • Shingles in severely immunosuppressed patient
  • Shingles in immunosuppressed patient where the rash is severe, widespread or patient is systemically unwell
  • Shingles affecting the head and neck
...
Does the patient meet (ANY) of the following criteria:
  • Immunosuppressed (see below)
  • Non-truncal involvement (shingles affecting the limbs, or perineum)
  • Moderate or severe pain
  • Moderate or severe rash (defined as confluent lesions)
  • All patients aged over 50 years
Does the patient meet (ANY) of the following crit...
Does the patient meet (ANY) of the following criteria:
  • Immunosuppressed (see below)
  • Continued vesicle formation
  • Severe pain
  • High risk of severe shingles (e.g. severe atopic dermatitis/eczema)
  • All patients aged 70 years and over
Does the patient meet (ANY) of the fo...
NO
NO
YES
YES
NO
NO
YES
YES
Patient does not meet treatment criteria
Share self-care and safety-netting advice
Patient does not meet treatm...
NO
NO
NO
NO
YES
YES
YES
YES
or if unsuitable
or if unsuitable
Offer aciclovir (subject to inclusion/exclusion criteria in PGD) plus self care
Offer aciclovir (subject to inclusion...
Offer valaciclovir (subject to inclusion/exclusion criteria in PGD) plus self care
Offer valaciclovir (subject to inclus...
Offer valaciclovir: 
Offer valaciclovir: 
  • Immunosuppressed patients
  • Adherence risk: already taking 8 or more medicines a day or is assisted in taking their medicines
Immunosuppressed patients Adherence risk: already taking 8 or mo...FOR IMMUNOSUPPRESSED PATIENTS
  • Offer treatment if appropriate and call patient’s GP or send urgent for action email if out of hours to notify supply of antiviral and request review by GP
  • Advise patient, if your symptoms worsen rapidly or if you become systemically unwell or the rash becomes severe or widespread - attend A&E or call 999
Offer treatment if appropriate and call patient’s GP or s...
Shingles
Shingles
NHS
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