The pain from shingles ranges from mild to severe. Adults with mild pain can try paracetamol alone or in combination with codeine or ibuprofen. If this does not work, or the person presents with, or develops, severe pain, referral is indicated. Prescribers may offer a trial of treatment intended for neuropathic pain, usually amitriptyline (off-label use), duloxetine (off-label use), gabapentin or pregabalin.

For early cases of shingles, a course of oral aciclovir, valaciclovir or famciclovir may be used. There is evidence that the earlier treatment is started within 72 hours of onset, the more it may reduce the severity and duration of the shingles episode.

Pharmacists may be able to initiate this early treatment through local or national arrangements. Community pharmacy PGDs, for example in Scotland, make more specific requirements for treatment initiation, usually relating to restricting to within 72 hours of onset, those with a single affected dermatome on the torso and in patients aged over 18 years. The PGDs also specify reasons for exclusion from pharmacy treatment where a GP should be involved.

A small number of patients may benefit from starting oral antivirals after 72 hours. Pharmacists may consider referral when there may be consideration of starting antivirals up to one 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 in severe pain).

Following the rash, persistent pain at the site – post-herpetic neuralgia – can develop and is seen more frequently in older people. It results from peripheral nerve damage caused by the herpes zoster virus. Pain that persists for 90 days or more after the onset of the rash is a commonly accepted definition for PHN.

On average, PHN lasts from three to six months, but can persist for longer, sometimes years. The severity of pain can vary and may be constant, intermittent or triggered by stimulation of the affected area, such as by wind on the face (allodynia). See Table 2 for more details.

The incidence of PHN is strongly related to age, ranging from 7 per cent of people aged between 50-59 years to 21 per cent aged between 60-69 years; 29 per cent aged between 70-79 years; and 34 per cent in those over the age of 80 years.

The most effective way of preventing PHN is with a herpes zoster (shingles) vaccine. Two vaccines are currently used in the NHS: Zostavax, a live attenuated vaccine given once; and Shingrix, a recombinant vaccine given twice. No booster dose is administered subsequently.

Studies have shown that giving older people (defined as adults aged over 60 years) the vaccine boosts waning immunity and significantly reduces morbidity from both shingles and PHN. If shingles does develop, symptom severity is greatly reduced and the incidence of PHN drops by two-thirds.

Herpes zoster vaccines are usually well-tolerated and recipients experience few systemic side-effects. Protection lasts for at least 10 years.

The NHS shingles vaccination programme began in 2013, using Zostavax, initially for patients aged over 70 years. As it is a live attenuated vaccine it is contraindicated in immunosuppressed people, pregnant women and children. In 2021 Shingrix was introduced for severely immunocompromised patients.

In the first five years of the routine programme using Zostavax in England (2013-18) there were significant reductions in hospitalisations for both shingles and PHN, and in consultations for PHN. These reductions were consistent with effectiveness in the routine cohorts (vaccinated aged 70+ years).

Overall, in England, an estimated 40,500 GP consultations and 1,840 hospitalisations were averted through vaccination with Zostavax.

From September 2023 the provision of shingles vaccine by the NHS has changed – both in the product used and the age threshold. There is evidence that Shingrix has greater efficacy and provides a substantially longer duration of protection from shingles than Zostavax, although a drawback is that for a full response it has to be given in two doses at least eight weeks apart. As it is a non-live recombinant vaccine it can be given to immunocompromised patients.

The Shingrix vaccine will replace Zostavax in the routine shingles programme and will require the two-dose schedule for all patient cohorts. It can be safely given at the same time as the flu jab.

• For immunocompromised patients: the eligible cohort of patients will expand to all patients aged 50 years and over (with no upper age limit). The programme aims to catch all severely immunocompromised individuals aged 50 years and over within the first year (see Green Book shingles chapter 28a for eligibility criteria – in Further Reading). The second dose should be given eight weeks to six months after the first dose for this cohort
• For immunocompetent patients: The eligible cohort of patients will expand to all those aged over 60 years, implemented in two stages over 10 years. For these people the second dose can be given six to 12 months after the first dose.

During stage 1 (September 1, 2023 to August 31, 2028) Shingrix will be offered to those turning 65 and 70 years on or after September 1, 2023. Zostavax will be offered to persons aged between 70 to 79 years that were eligible for the vaccination programme before September 1, 2023. Once all stocks of Zostavax are exhausted, these individuals can be offered Shingrix if they have not previously been given a shingles vaccine.

During stage 2 (September 1, 2028 to August 31, 2033): Shingrix will be offered to those turning 60 and 65 years of age. From September 1, 2033 and thereafter, Shingrix will be offered routinely at age 60 years.