Pharmacy First: Shingles

About this service

Shingles (herpes zoster) is a reactivation of the varicella zoster virus, presenting as a painful unilateral rash in a dermatomal distribution. The NHS Pharmacy First service allows pharmacists to supply antivirals to adults aged 18 and over within defined treatment time windows.

Early antiviral treatment reduces the severity and duration of the acute episode and, importantly, reduces the risk of post-herpetic neuralgia, which can cause prolonged and debilitating pain after the rash resolves. The benefit of treatment is greatest when started within 72 hours of rash onset.

Two antivirals are available under this pathway: aciclovir (PGD 2a) and valaciclovir (PGD 2b). Both have the same clinical indications and the same exclusion criteria, but valaciclovir is dosed three times daily compared with aciclovir five times daily. Valaciclovir is therefore preferred for patients on many medicines, those with carer-assisted medication taking, and immunosuppressed patients where adherence to a five-times-daily regimen may be difficult.

A significant change in PGD version 1.1 (October 2025) was the addition of head and neck shingles as an exclusion criterion from both PGDs. Pharmacists should ensure they are working to the current version.

Who to offer the service to

Include

• Adults aged 18 and over
• Diagnosis of shingles confirmed (unilateral dermatomal rash, characteristic appearance)
• Treatment can be started within 72 hours of rash onset AND any of: non-truncal involvement (limbs or perineum), moderate or severe pain, moderate or severe rash (confluent lesions), aged over 50 years
• OR: treatment can be started within 7 days of rash onset AND any of: continued vesicle formation, severe pain, high risk of severe shingles (e.g. severe eczema or atopic dermatitis), aged 70 years and over
• OR: immunosuppressed (non-severely) within 7 days, rash not widespread or severe, systemically well: use valaciclovir PGD 2b
• NHS eligibility requirements apply

Exclude

• Under 18 years of age: outside this pathway
• Pregnancy or suspected pregnancy: refer to GP urgently
• Rash onset more than 7 days ago: outside treatment window. Refer to GP.
• Shingles affecting the head or neck: excluded from both PGDs (v1.1 update, October 2025). Refer to GP or A&E depending on severity.
• Ophthalmic shingles: Hutchinson's sign (rash on tip, side, or root of nose), visual symptoms, or unexplained red eye: A&E urgently
• Serious neurological complications suspected: meningitis, encephalitis, myelitis, or facial nerve palsy (Ramsay Hunt syndrome): A&E urgently
• Severely immunosuppressed: A&E urgently
• Immunosuppressed with widespread or severe rash, or systemically unwell: A&E urgently
• Any underlying neurological condition: excluded from both PGDs. Refer to GP.
• Known CKD stage 4 or 5 (eGFR below 30): excluded from aciclovir. Refer to GP.
• Known CKD stage 3, 4, or 5 (eGFR below 60): excluded from valaciclovir. Refer to GP.
• Currently on long-term aciclovir or valaciclovir prophylaxis: excluded
• Concurrent ciclosporin, tacrolimus, mycophenolate, aminophylline, or theophylline: must not supply under either PGD. Refer to prescriber.
• Failed previous antiviral treatment for this episode: refer to GP
• Sepsis suspected: call 999

How to deliver the service

1. Check for red flags before any assessment Before taking a history, screen for conditions requiring immediate referral. Ophthalmic involvement: Hutchinson's sign (rash on the tip, side, or root of the nose), visual symptoms, or unexplained red eye requires A&E referral, as ophthalmic shingles can cause permanent corneal damage. Neurological complications: meningitis, encephalitis, myelitis, or facial nerve palsy (Ramsay Hunt syndrome, which presents with ear pain, vesicles in the ear canal, and unilateral facial weakness) all require A&E. Severely immunosuppressed patients or immunosuppressed patients with widespread rash or systemic illness should also be referred to A&E.
2. Confirm age, rash site, and time since onset Confirm the patient is aged 18 or over. Establish when the rash first appeared: this sets the treatment window, and the clock runs from rash onset not from symptom onset. Head and neck shingles (including the scalp, face, and neck) is excluded from both PGDs under the v1.1 update (October 2025). Shingles on the trunk (back, chest, abdomen) and on the limbs or perineum remain in scope. Confirm the rash is unilateral and dermatomal.
3. Apply the time window criteria Within 72 hours: antiviral treatment is supported if the patient has non-truncal involvement, moderate or severe pain, confluent rash, or is aged over 50. Within 7 days: treatment is supported if there are still new vesicles forming, pain is severe, the patient has a high risk of severe shingles, or is aged 70 or over. Beyond 7 days from rash onset: outside the treatment window. Refer to GP.
4. Choose aciclovir or valaciclovir based on patient factors Both antivirals are equally effective. Use valaciclovir (three times daily) for patients on 8 or more medicines, those with carer-assisted medication taking, or immunosuppressed patients (non-severely). For all others, aciclovir (five times daily) may be used. Check renal function: valaciclovir requires eGFR 60 or above; aciclovir requires eGFR 30 or above. Check for ciclosporin, tacrolimus, mycophenolate, aminophylline, and theophylline (must not supply under either PGD). Caution with nephrotoxic medicines: ACE inhibitors, ARBs, diuretics, NSAIDs, metformin. Advise maintaining adequate fluid intake throughout treatment.
5. Counsel on treatment, contagion, and safety netting Antiviral counselling: complete the full 7-day course even if the rash improves. Aciclovir should be taken every 4 hours during waking hours (5 doses over 16 hours). Maintain adequate hydration, particularly in older patients. Topical creams and adhesive dressings should be avoided on the rash as they delay healing. Pain management: paracetamol alone or with codeine, or ibuprofen if appropriate. Refer to GP if pain is not controlled by over-the-counter analgesia. Contagion: shingles can transmit chickenpox (not shingles) to people who have not had chickenpox or the vaccine. The patient is infectious until all vesicles are crusted (usually 5-7 days from rash onset). Advise avoiding contact with pregnant individuals, immunosuppressed individuals, and babies under 1 month old. Cover weeping lesions not under clothing. No need to stay off work if the rash is covered and not weeping. After recovery: signpost to discuss shingles vaccination with their GP.

Assessment outcome: what to do

Treatment Time Windows: When Antivirals Apply

Both aciclovir and valaciclovir use the same inclusion criteria. The time window runs from rash onset, not from when symptoms first started.

Aciclovir versus Valaciclovir: Which to Choose

Both are effective. The choice is guided by patient factors rather than clinical efficacy. Both are given for 7 days.

Recording and submission

• Complete the consultation record contemporaneously on PharmOutcomes.
• Key information to record:
  • Patient name, date of birth, NHS number
  • Age confirmed (18 and over)
  • Date of rash onset and time since onset confirmed
  • Rash site: dermatomal distribution, laterality, truncal or non-truncal, head/neck assessed and excluded
  • Ophthalmic features assessed and absent (Hutchinson's sign, visual symptoms, red eye)
  • Neurological complications assessed and absent
  • Pregnancy excluded
  • Immunosuppression status assessed (nil, immunosuppressed, or severely immunosuppressed)
  • Inclusion criteria met: which clinical features support treatment (pain level, rash severity, age, vesicle formation)
  • Antiviral selected and rationale: aciclovir or valaciclovir and reason for choice
  • Renal function: CKD status assessed
  • Drug interactions checked (ciclosporin, tacrolimus, mycophenolate, aminophylline, theophylline)
  • Medicine supplied: name, strength, dose, frequency, duration, quantity, batch number, expiry date
  • Pain management advice given
  • Contagion advice given (contacts to avoid, rash covering, work/school)
  • Safety netting provided

Key takeaways

• Treatment must start within 72 hours for most patients (or within 7 days for those aged 70 and over, with continued vesicle formation, severe pain, or high risk). Head and neck shingles is excluded from both PGDs under the v1.1 update. Always check for Hutchinson's sign and ophthalmic features before supplying.
• Choose valaciclovir (1g three times daily for 7 days) over aciclovir (800mg five times daily for 7 days) for patients on 8 or more medicines, carer-assisted medication, or non-severe immunosuppression. Valaciclovir has a stricter renal threshold: excluded if eGFR is below 60.
• Advise patients to avoid topical creams and dressings on the rash, maintain hydration, and avoid contact with pregnant individuals, immunosuppressed individuals, and babies under 1 month old until all vesicles are crusted.

Download the checklist