Pharmacy First for shingles

Pharmacy teams seeing patients asking about or presenting with signs and symptoms of shingles can explain about the Pharmacy First service for shingles that may enable the pharmacist to offer them treatment and advice that can help.

The NHS Pharmacy First clinical pathway for shingles is for adults aged 18 years and over who are not pregnant. The pharmacist will invite the person into the consultation room and work through the pathway in order to diagnose shingles on the basis of typical clinical features, while also considering the risk to the patient of deterioration or serious illness.

The first thing the pharmacist will look for are suspected serious complications such as meningitis (neck stiffness, photophobia, mottled skin), encephalitis (disorientation, changes in behaviour), myelitis (muscle weakness, loss of bladder or bowel control), and facial nerve paralysis. They will also check for shingles in or around the eyes, and a rash on the tip, side, or root of the nose. If the pharmacist knows the patient is severely immunosuppressed they will check if the rash is severe, widespread or the patient is systemically unwell. If any of these signs and symptoms are present, the pharmacist will signpost the patient to A&E or call 999.

If these complications are not present, the pharmacist will next check if the patient shows the typical progression of shingles clinical features. The 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. Shingles rash appears as a group of red spots on a pink-red background and usually appears within two to three days after the onset of pain, and quickly turns into small fluid-filled blisters. The rash usually covers a well-defined area of skin on one side of the body only (right or left) and will not cross to the other side of the body.

If the patient does not display the clinical features that suggest the typical progression of shingles, then the pharmacist will determine that shingles is less likely, and will consider an alternative diagnosis and proceed appropriately.

However, if the pharmacist thinks the patient does follow these typical progression of shingles clinical features and shingles is more likely, this is the gateway point for the Pharmacy First service.

At this point the pharmacist will determine whether the patient has shingles within 72 hours of rash onset, or within up to one week after rash onset. If neither of these are the case, then the person does not meet the treatment criteria via Pharmacy First, and they will instead be given self care and safety-netting advice.

However, if the patient does have shingles within 72 hours of rash onset, then the pharmacist will next consider if they meet any of the following criteria:

• Immunosuppressed
• Non-truncal involvement (shingles affecting the neck, limbs, or perineum)
• Moderate or severe pain
• Moderate or severe rash (defined as confluent lesions)
• All patients aged over 50 years.

Similarly, if the patient has shingles up to one week after rash onset then the pharmacist will see if they also meet any of the following criteria:

• Immunosuppressed
• Continued vesicle (blister) formation
• Severe pain
• High risk of severe shingles (e.g. severe atopic dermatitis/eczema)
• All patients aged 70 years and over.

If none of these apply, the pharmacist will share self care and safety-netting advice with the patient. However, if these criteria do apply, the pharmacist will offer aciclovir subject to inclusion/exclusion criteria in PGD plus self care advice, or if aciclovir is unsuitable will offer valaciclovir subject to inclusion/exclusion criteria in the Pharmacy First shingles PGD plus self care advice.

In addition, immunosuppressed patients will be offered treatment if appropriate and the pharmacist will also call the person’s GP or send an ‘urgent for action’ email if out of hours to notify that they have supplied an antiviral and request review by GP. They will also advise the patient to attend A&E or call 999 if their symptoms worsen rapidly, they become systemically unwell or the rash becomes severe or widespread.

All patients will be given self care and safety-netting advice using the British Association of Dermatologists shingles leaflet: bad.org.uk/pils/shingles-herpes-zoster, as well as being recommended paracetamol, a NSAID such as ibuprofen, or co-codamol over the counter for pain management. If this is not effective, the patient can then be referred back to their GP. In addition, all eligible individuals can be signposted to information and advice about receiving the shingles vaccine after they have recovered from this episode of shingles.