Clinical Guides
Shingles (Herpes Zoster)
A clinically focused clinical guide to shingles in Indian practice, covering early antivirals, pain, ocular and otic disease, dissemination, immune compromise, pregnancy, referral and vaccination.
MedNext Academy | 12 min read
Shingles (Herpes Zoster)
A clinically focused clinical guide to shingles in Indian practice, covering early antivirals, pain, ocular and otic disease, dissemination, immune compromise, pregnancy, referral and vaccination.
Summary
Shingles is reactivation of latent varicella-zoster virus in a sensory ganglion, usually causing painful unilateral grouped vesicles in one or adjacent dermatomes. Diagnose clinically when typical, consider lesion PCR when atypical, and discuss acyclovir, valacyclovir or famciclovir early. Antivirals work best within 72 hours; later treatment may still matter for new lesions, severe, ocular, neurological, disseminated or immunocompromised disease. Ask about prodrome, rash onset, new lesions, pain, visual symptoms, ear symptoms, weakness, confusion, pregnancy, kidney disease, medicines and immune suppression. Examine dermatomes, eye, ear, cranial nerves and systemic state. Offer antiviral treatment promptly, adjust for renal function and interactions, and use intravenous therapy only in hospital for selected severe or visceral disease. Antibiotics do not treat VZV. Same-day ophthalmology is required for eyelid or nasal rash, red eye, photophobia or visual change. Ear vesicles with facial weakness, hearing loss or vertigo need urgent ENT or hospital review. Indian services vary in PCR, specialist and vaccine access. Verify current local vaccine policy; recombinant zoster vaccine prevents disease but does not treat an active episode. Atypical, recurrent, extensive or immunocompromised disease merits lesion PCR and immune assessment as indicated. Do not delay eye, neurological or hospital referral while awaiting a test. Use skin care, lesion covering and a staged analgesic plan. Assess sleep, function, mood, sedation, falls and persistent neuropathic pain rather than repeatedly prescribing antivirals.
How Common Is It?
Shingles is reactivation of latent varicella-zoster virus in a sensory ganglion, usually causing painful unilateral grouped vesicles in one or adjacent dermatomes. Diagnose clinically when typical, consider lesion PCR when atypical, and discuss acyclovir, valacyclovir or famciclovir early. Antivirals work best within 72 hours; later treatment may still matter for new lesions, severe, ocular, neurological, disseminated or immunocompromised disease. Atypical, recurrent, extensive or immunocompromised disease merits lesion PCR and immune assessment as indicated. Do not delay eye, neurological or hospital referral while awaiting a test. Use skin care, lesion covering and a staged analgesic plan. Assess sleep, function, mood, sedation, falls and persistent neuropathic pain rather than repeatedly prescribing antivirals. Disseminated lesions, pneumonitis, encephalitis, meningism, weakness, dehydration, necrosis or immunocompromise lower the threshold for admission. Cover lesions until crusted and avoid susceptible contacts. NMC learning includes rash mapping, eye and cranial-nerve examination, transmission counselling, renal prescribing, referral urgency, stigma-sensitive communication and supervised specialist care. Offer antiviral treatment promptly, adjust for renal function and interactions, and use intravenous therapy only in hospital for selected severe or visceral disease. Antibiotics do not treat VZV. Same-day ophthalmology is required for eyelid or nasal rash, red eye, photophobia or visual change. Ear vesicles with facial weakness, hearing loss or vertigo need urgent ENT or hospital review.
Risk Factors
Shingles is reactivation of latent varicella-zoster virus in a sensory ganglion, usually causing painful unilateral grouped vesicles in one or adjacent dermatomes. Diagnose clinically when typical, consider lesion PCR when atypical, and discuss acyclovir, valacyclovir or famciclovir early. Antivirals work best within 72 hours; later treatment may still matter for new lesions, severe, ocular, neurological, disseminated or immunocompromised disease. Offer antiviral treatment promptly, adjust for renal function and interactions, and use intravenous therapy only in hospital for selected severe or visceral disease. Antibiotics do not treat VZV. Same-day ophthalmology is required for eyelid or nasal rash, red eye, photophobia or visual change. Ear vesicles with facial weakness, hearing loss or vertigo need urgent ENT or hospital review. Indian services vary in PCR, specialist and vaccine access. Verify current local vaccine policy; recombinant zoster vaccine prevents disease but does not treat an active episode. Ask about prodrome, rash onset, new lesions, pain, visual symptoms, ear symptoms, weakness, confusion, pregnancy, kidney disease, medicines and immune suppression. Examine dermatomes, eye, ear, cranial nerves and systemic state. Use skin care, lesion covering and a staged analgesic plan. Assess sleep, function, mood, sedation, falls and persistent neuropathic pain rather than repeatedly prescribing antivirals. Disseminated lesions, pneumonitis, encephalitis, meningism, weakness, dehydration, necrosis or immunocompromise lower the threshold for admission. Cover lesions until crusted and avoid susceptible contacts.
Diagnosis
Shingles is reactivation of latent varicella-zoster virus in a sensory ganglion, usually causing painful unilateral grouped vesicles in one or adjacent dermatomes. Diagnose clinically when typical, consider lesion PCR when atypical, and discuss acyclovir, valacyclovir or famciclovir early. Antivirals work best within 72 hours; later treatment may still matter for new lesions, severe, ocular, neurological, disseminated or immunocompromised disease. Use skin care, lesion covering and a staged analgesic plan. Assess sleep, function, mood, sedation, falls and persistent neuropathic pain rather than repeatedly prescribing antivirals. Disseminated lesions, pneumonitis, encephalitis, meningism, weakness, dehydration, necrosis or immunocompromise lower the threshold for admission. Cover lesions until crusted and avoid susceptible contacts. NMC learning includes rash mapping, eye and cranial-nerve examination, transmission counselling, renal prescribing, referral urgency, stigma-sensitive communication and supervised specialist care. Atypical, recurrent, extensive or immunocompromised disease merits lesion PCR and immune assessment as indicated. Do not delay eye, neurological or hospital referral while awaiting a test.
History
Ask about prodrome, rash onset, new lesions, pain, visual symptoms, ear symptoms, weakness, confusion, pregnancy, kidney disease, medicines and immune suppression. Examine dermatomes, eye, ear, cranial nerves and systemic state.
Examination
Atypical, recurrent, extensive or immunocompromised disease merits lesion PCR and immune assessment as indicated. Do not delay eye, neurological or hospital referral while awaiting a test.
Investigations
Offer antiviral treatment promptly, adjust for renal function and interactions, and use intravenous therapy only in hospital for selected severe or visceral disease. Antibiotics do not treat VZV.
Differential Diagnosis
Shingles is reactivation of latent varicella-zoster virus in a sensory ganglion, usually causing painful unilateral grouped vesicles in one or adjacent dermatomes. Diagnose clinically when typical, consider lesion PCR when atypical, and discuss acyclovir, valacyclovir or famciclovir early. Antivirals work best within 72 hours; later treatment may still matter for new lesions, severe, ocular, neurological, disseminated or immunocompromised disease. Same-day ophthalmology is required for eyelid or nasal rash, red eye, photophobia or visual change. Ear vesicles with facial weakness, hearing loss or vertigo need urgent ENT or hospital review. Indian services vary in PCR, specialist and vaccine access. Verify current local vaccine policy; recombinant zoster vaccine prevents disease but does not treat an active episode. Ask about prodrome, rash onset, new lesions, pain, visual symptoms, ear symptoms, weakness, confusion, pregnancy, kidney disease, medicines and immune suppression. Examine dermatomes, eye, ear, cranial nerves and systemic state. Offer antiviral treatment promptly, adjust for renal function and interactions, and use intravenous therapy only in hospital for selected severe or visceral disease. Antibiotics do not treat VZV. Disseminated lesions, pneumonitis, encephalitis, meningism, weakness, dehydration, necrosis or immunocompromise lower the threshold for admission. Cover lesions until crusted and avoid susceptible contacts. NMC learning includes rash mapping, eye and cranial-nerve examination, transmission counselling, renal prescribing, referral urgency, stigma-sensitive communication and supervised specialist care.
Management
Shingles is reactivation of latent varicella-zoster virus in a sensory ganglion, usually causing painful unilateral grouped vesicles in one or adjacent dermatomes. Diagnose clinically when typical, consider lesion PCR when atypical, and discuss acyclovir, valacyclovir or famciclovir early. Antivirals work best within 72 hours; later treatment may still matter for new lesions, severe, ocular, neurological, disseminated or immunocompromised disease. Disseminated lesions, pneumonitis, encephalitis, meningism, weakness, dehydration, necrosis or immunocompromise lower the threshold for admission. Cover lesions until crusted and avoid susceptible contacts. NMC learning includes rash mapping, eye and cranial-nerve examination, transmission counselling, renal prescribing, referral urgency, stigma-sensitive communication and supervised specialist care. Atypical, recurrent, extensive or immunocompromised disease merits lesion PCR and immune assessment as indicated. Do not delay eye, neurological or hospital referral while awaiting a test. Use skin care, lesion covering and a staged analgesic plan. Assess sleep, function, mood, sedation, falls and persistent neuropathic pain rather than repeatedly prescribing antivirals. Indian services vary in PCR, specialist and vaccine access. Verify current local vaccine policy; recombinant zoster vaccine prevents disease but does not treat an active episode. Ask about prodrome, rash onset, new lesions, pain, visual symptoms, ear symptoms, weakness, confusion, pregnancy, kidney disease, medicines and immune suppression. Examine dermatomes, eye, ear, cranial nerves and systemic state.
Prescribing Information
Shingles is reactivation of latent varicella-zoster virus in a sensory ganglion, usually causing painful unilateral grouped vesicles in one or adjacent dermatomes. Diagnose clinically when typical, consider lesion PCR when atypical, and discuss acyclovir, valacyclovir or famciclovir early. Antivirals work best within 72 hours; later treatment may still matter for new lesions, severe, ocular, neurological, disseminated or immunocompromised disease. Indian services vary in PCR, specialist and vaccine access. Verify current local vaccine policy; recombinant zoster vaccine prevents disease but does not treat an active episode. Ask about prodrome, rash onset, new lesions, pain, visual symptoms, ear symptoms, weakness, confusion, pregnancy, kidney disease, medicines and immune suppression. Examine dermatomes, eye, ear, cranial nerves and systemic state. Offer antiviral treatment promptly, adjust for renal function and interactions, and use intravenous therapy only in hospital for selected severe or visceral disease. Antibiotics do not treat VZV. Same-day ophthalmology is required for eyelid or nasal rash, red eye, photophobia or visual change. Ear vesicles with facial weakness, hearing loss or vertigo need urgent ENT or hospital review. NMC learning includes rash mapping, eye and cranial-nerve examination, transmission counselling, renal prescribing, referral urgency, stigma-sensitive communication and supervised specialist care. Atypical, recurrent, extensive or immunocompromised disease merits lesion PCR and immune assessment as indicated. Do not delay eye, neurological or hospital referral while awaiting a test.
When to Refer
Shingles is reactivation of latent varicella-zoster virus in a sensory ganglion, usually causing painful unilateral grouped vesicles in one or adjacent dermatomes. Diagnose clinically when typical, consider lesion PCR when atypical, and discuss acyclovir, valacyclovir or famciclovir early. Antivirals work best within 72 hours; later treatment may still matter for new lesions, severe, ocular, neurological, disseminated or immunocompromised disease. NMC learning includes rash mapping, eye and cranial-nerve examination, transmission counselling, renal prescribing, referral urgency, stigma-sensitive communication and supervised specialist care. Atypical, recurrent, extensive or immunocompromised disease merits lesion PCR and immune assessment as indicated. Do not delay eye, neurological or hospital referral while awaiting a test. Use skin care, lesion covering and a staged analgesic plan. Assess sleep, function, mood, sedation, falls and persistent neuropathic pain rather than repeatedly prescribing antivirals. Disseminated lesions, pneumonitis, encephalitis, meningism, weakness, dehydration, necrosis or immunocompromise lower the threshold for admission. Cover lesions until crusted and avoid susceptible contacts. Ask about prodrome, rash onset, new lesions, pain, visual symptoms, ear symptoms, weakness, confusion, pregnancy, kidney disease, medicines and immune suppression. Examine dermatomes, eye, ear, cranial nerves and systemic state. Offer antiviral treatment promptly, adjust for renal function and interactions, and use intravenous therapy only in hospital for selected severe or visceral disease. Antibiotics do not treat VZV.
Red Flags
- Vesicles on the tip, side, or root of the nose (Hutchinson's sign) — indicates nasociliary branch involvement and high risk of herpes zoster ophthalmicus. URGENT ophthalmology referral within 24 hours
- Any eye symptoms (pain, redness, visual disturbance, photophobia) with V1 (ophthalmic) dermatome rash — herpes zoster ophthalmicus, can cause keratitis, uveitis, acute retinal necrosis. Same-day ophthalmology
- Facial nerve palsy with vesicles in the ear canal or on the pinna — Ramsay Hunt syndrome (herpes zoster oticus). Start antivirals + prednisolone immediately, ENT referral
- Disseminated shingles (>20 vesicles outside the primary dermatome) — indicates viraemia, especially in immunocompromised patients. Hospital admission for IV aciclovir
- Motor weakness in the affected dermatome — zoster-associated motor neuropathy. Can affect limbs (wrist/foot drop), bladder (urinary retention from sacral zoster), or diaphragm
- Immunocompromised patient with shingles (HIV/AIDS, transplant recipients, chemotherapy, high-dose steroids) — higher risk of dissemination, visceral involvement, and post-herpetic neuralgia. Consider IV aciclovir
- Severe haemorrhagic or necrotic rash — may indicate coagulopathy or deep immunosuppression
- Meningeal signs (headache, neck stiffness, photophobia) — zoster meningitis/encephalitis, especially in elderly or immunocompromised. LP and IV aciclovir
Indian Clinical Context
Herpes zoster management in India has several practical considerations. Aciclovir (oral and IV) is widely available and affordable as Indian generics [Zovirax, Acivir — Rs 3-5 per 800 mg tablet]. Valaciclovir [Valcivir, Valacyclovir — Rs 15-25 per 1000 mg tablet] has better bioavailability and simpler dosing (1000 mg TDS vs 800 mg 5 times daily for aciclovir) and is increasingly preferred. Famciclovir is available but more expensive and rarely used in Indian practice.
The shingles vaccine (Shingrix, recombinant adjuvanted) was approved in India in 2023 but remains expensive (approximately Rs 12,000-15,000 per dose, two doses required) and is not included in the national immunisation programme. It is recommended for adults aged ≥50 years and immunocompromised individuals aged ≥18 years but uptake is very low due to cost and limited awareness.
Post-herpetic neuralgia (PHN) management in India commonly uses amitriptyline [Tryptomer — Rs 1-2 per 25 mg tablet] as first-line given its availability and extremely low cost. Pregabalin [Pregabalin — Rs 5-10 per 75 mg capsule] and gabapentin [Gabapin — Rs 3-7 per 300 mg capsule] are widely available alternatives. Capsaicin cream and lidocaine patches are available but expensive and often not covered by insurance.
Misdiagnosis is common in the pre-vesicular stage — dermatomal pain without visible rash is frequently labelled as musculoskeletal pain, cardiac pain (left thoracic dermatome), or renal colic (lumbar dermatome). A high index of suspicion for prodromal zoster in elderly patients with new-onset unilateral dermatomal pain is important.
HIV testing should be considered in patients aged <50 with shingles, especially multidermatomal or recurrent zoster, as it may be the presenting feature of undiagnosed HIV infection.
NMC Competency Mapping
- DR8.1 -- Describe the aetiology, pathogenesis and clinical features of herpes zoster (shingles)
- DR8.2 -- Describe the management of herpes zoster including antiviral therapy and pain management
- DR8.3 -- Identify and manage complications of herpes zoster including post-herpetic neuralgia and herpes zoster ophthalmicus
- OP4.1 -- Enumerate the causes of red eye and describe the clinical features and management of herpes zoster ophthalmicus
- PH1.45 -- Describe the mechanism of action, types, doses, side effects and indications of antiviral agents including aciclovir and valaciclovir
- IM3.18 -- Describe the approach to a patient with vesicular skin lesions and fever
Key Exam Pearls for NEET PG
Shingles is reactivation of latent varicella-zoster virus in a sensory ganglion, usually causing painful unilateral grouped vesicles in one or adjacent dermatomes. Diagnose clinically when typical, consider lesion PCR when atypical, and discuss acyclovir, valacyclovir or famciclovir early. Antivirals work best within 72 hours; later treatment may still matter for new lesions, severe, ocular, neurological, disseminated or immunocompromised disease. Use skin care, lesion covering and a staged analgesic plan. Assess sleep, function, mood, sedation, falls and persistent neuropathic pain rather than repeatedly prescribing antivirals. Disseminated lesions, pneumonitis, encephalitis, meningism, weakness, dehydration, necrosis or immunocompromise lower the threshold for admission. Cover lesions until crusted and avoid susceptible contacts. NMC learning includes rash mapping, eye and cranial-nerve examination, transmission counselling, renal prescribing, referral urgency, stigma-sensitive communication and supervised specialist care. Atypical, recurrent, extensive or immunocompromised disease merits lesion PCR and immune assessment as indicated. Do not delay eye, neurological or hospital referral while awaiting a test. Same-day ophthalmology is required for eyelid or nasal rash, red eye, photophobia or visual change. Ear vesicles with facial weakness, hearing loss or vertigo need urgent ENT or hospital review. Indian services vary in PCR, specialist and vaccine access. Verify current local vaccine policy; recombinant zoster vaccine prevents disease but does not treat an active episode.
Frequently Asked Questions
When do antiviral medicines help most in shingles?
Treatment is most effective within 72 hours. Later treatment may still be appropriate for new lesions, severe, ophthalmic, neurological, disseminated or immunocompromised disease, with renal and interaction checks. Explain the reasoning, document safety checks, and arrange timely review whenever symptoms, examination or treatment response is concerning.
When is a shingles rash an urgent eye emergency?
Same-day eye assessment is needed for eyelid or nasal rash, red or painful eye, photophobia or visual change because ocular zoster can threaten the cornea and vision. Do not wait for routine review. Explain the reasoning, document safety checks, and arrange timely review whenever symptoms, examination or treatment response is concerning.
Can a person with shingles transmit infection to others?
Lesion fluid can transmit VZV to a susceptible person, causing chickenpox. Cover lesions and avoid susceptible pregnant people, newborns and immunocompromised contacts until crusted and dry. Explain the reasoning, document safety checks, and arrange timely review whenever symptoms, examination or treatment response is concerning.
Does zoster vaccination treat an active shingles episode?
No. Recombinant zoster vaccine is preventive. Discuss eligibility, timing and availability after recovery using current Indian or specialist recommendations; vaccination does not replace treatment or referral. Explain the reasoning, document safety checks, and arrange timely review whenever symptoms, examination or treatment response is concerning.
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