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 can reduce the severity of acute symptoms, limit viral shedding and new lesion formation, and shorten the duration of acute pain. It should not be presented as reliably preventing post-herpetic neuralgia: high-quality evidence shows that oral aciclovir does not significantly reduce post-herpetic neuralgia incidence, and evidence for other antivirals remains insufficient. Treatment benefit is greatest when started within 72 hours of rash onset.

Two antivirals are available under this service: aciclovir under PGD 2a and valaciclovir under PGD 2b. These are not interchangeable alternatives for all eligible patients. Aciclovir PGD 2a applies to adults meeting the standard Pharmacy First shingles inclusion criteria. Valaciclovir PGD 2b applies where either: the standard 72-hour or 7-day treatment criteria are met and aciclovir adherence is unlikely because of carer-assisted medication or 8 or more medicines daily; or the patient is non-severely immunosuppressed, within 7 days of rash onset, systemically well, and the rash is not widespread or severe.

Version 1.1, valid from 1 October 2025, added head and neck shingles as an exclusion criterion from both PGDs. Pharmacists must confirm 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: non-severely immunosuppressed, within 7 days of rash onset, 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
• Currently breastfeeding with shingles sore(s) on the breast(s): excluded from both PGDs. Refer to GP or prescriber. If lesions are not on the breast, treatment may be used with advice to avoid infant contact with sores and to monitor the infant for diarrhoea, vomiting, rashes, irritability, lethargy, or fever.
• 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). Without ophthalmic, neurological, or systemic features: refer urgently to a prescriber or GP. With Hutchinson's sign, visual symptoms, unexplained red eye, serious neurological complications, suspected sepsis, or severe immunosuppression: A&E immediately.
• 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.
• Inability to absorb oral medicines or to swallow oral dosage formulations (tablets or dispersible tablets): excluded from both PGDs. Refer to GP.
• At risk of dehydration and unable to maintain adequate fluid intake: excluded from both PGDs. Refer to GP.
• Known hypersensitivity to aciclovir, valaciclovir, or any component of the formulation: excluded. Check excipients where relevant: aciclovir formulations may contain lactose, sucrose, fructose, sorbitol, or aspartame; patients with phenylketonuria must not use medicines containing aspartame. Check the Summary of Product Characteristics before supplying.
• Known CKD stage 4 or 5 (eGFR below 30): excluded from aciclovir PGD 2a. Refer to GP.
• Known CKD stage 3, 4, or 5 (eGFR below 60): excluded from valaciclovir PGD 2b. Refer to GP.
• Currently on long-term aciclovir or valaciclovir prophylaxis: excluded from both PGDs
• 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. Head or neck shingles (including scalp, face, and neck) is excluded from both PGDs under the v1.1 update (October 2025): without ophthalmic, neurological, or systemic features, refer urgently to a prescriber or GP; with Hutchinson's sign, visual symptoms, unexplained red eye, serious neurological complications, suspected sepsis, or severe immunosuppression, refer to A&E immediately. Neurological complications: meningitis, encephalitis, myelitis, or facial nerve palsy (Ramsay Hunt syndrome, presenting 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 go 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 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. Select the correct PGD and antiviral Supply aciclovir under PGD 2a for patients meeting the standard inclusion criteria, unless aciclovir is not appropriate under PGD 2a because the patient has carer-assisted medication taking, is prescribed 8 or more medicines daily, or is non-severely immunosuppressed. In those cases, use valaciclovir under PGD 2b, provided its own inclusion criteria are met. Check renal function: aciclovir PGD 2a requires eGFR 30 or above; valaciclovir PGD 2b requires eGFR 60 or above. Check for ciclosporin, tacrolimus, mycophenolate, aminophylline, and theophylline: must not supply under either PGD. Caution with nephrotoxic medicines including ACE inhibitors, ARBs, diuretics, NSAIDs, metformin, and tenofovir disoproxil fumarate: patients taking tenofovir for hepatitis B, HIV PrEP, or PEP should contact their provider for additional monitoring advice due to the increased risk of renal impairment; aciclovir may still be supplied but the patient must be informed. Confirm adequate fluid intake can be maintained: patients unable to maintain fluid intake are excluded from both PGDs. For valaciclovir: counsel that Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a named specific risk. If DRESS occurs, valaciclovir must not be restarted. Advise the patient to seek immediate medical attention if they develop widespread rash, fever, swollen lymph nodes, or signs of organ involvement during 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. Seek medical advice if new vesicles are forming after 7 days of antiviral treatment, or if healing is delayed. 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 to 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: advise the patient to discuss shingles vaccination with their GP to reduce the risk of future episodes.

Assessment outcome: what to do

Treatment Time Windows: When Antivirals Apply

Aciclovir PGD 2a applies to adults meeting the standard Pharmacy First shingles inclusion criteria. Valaciclovir PGD 2b applies where either: the standard 72-hour or 7-day treatment criteria are met and aciclovir adherence is unlikely because of carer-assisted medication or 8 or more medicines daily; or the patient is non-severely immunosuppressed, within 7 days of rash onset, systemically well, and the rash is not widespread or severe. The time window runs from rash onset, not from when symptoms first appeared.

Aciclovir versus Valaciclovir: PGD Governance

Aciclovir PGD 2a is the standard treatment for eligible patients. Valaciclovir PGD 2b is a PGD-restricted pathway for patients where aciclovir is not appropriate because of carer-assisted medication taking, 8 or more medicines daily, or non-severe immunosuppression. Both are given for 7 days.

Recording and submission

• Complete the consultation record contemporaneously on PharmOutcomes.
• Key information to record:
  • Informed consent obtained and documented
  • 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
  • Breastfeeding status checked: if breastfeeding, confirm shingles sores not on breast(s)
  • Immunosuppression status assessed (nil, non-severely immunosuppressed, or severely immunosuppressed)
  • Inclusion criteria met: which clinical features support treatment (pain level, rash severity, age, vesicle formation)
  • PGD selected: aciclovir PGD 2a or valaciclovir PGD 2b, with rationale
  • Renal function: CKD status assessed; eGFR threshold confirmed for selected PGD
  • Drug interactions checked (ciclosporin, tacrolimus, mycophenolate, aminophylline, theophylline)
  • Ability to absorb oral medicines and swallow tablets or dispersible tablets confirmed
  • Adequate hydration can be maintained confirmed
  • Hypersensitivity to aciclovir, valaciclovir, or excipients excluded
  • 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: return if worsening, if new vesicles forming after 7 days of treatment, if pain not controlled, or if healing delayed

Key takeaways

• Aciclovir PGD 2a is the standard treatment for eligible patients. Valaciclovir PGD 2b is a restricted pathway only for patients where aciclovir is excluded due to carer-assisted medication, 8 or more medicines daily, or non-severe immunosuppression. Treatment window is 72 hours for most patients, or up to 7 days if any one of the following applies: aged 70 years and over, continued vesicle formation, severe pain, or high risk of severe shingles. Head and neck shingles is excluded from both PGDs (Version 1.1, valid from 1 October 2025).
• Confirm renal function before selecting the antiviral: aciclovir requires eGFR 30 or above; valaciclovir requires eGFR 60 or above. Check for ciclosporin, tacrolimus, mycophenolate, aminophylline, and theophylline, which are absolute contraindications to both PGDs. Screen for breastfeeding with breast lesions, inability to swallow, risk of dehydration, and hypersensitivity before supplying.
• Advise patients to avoid topical creams and dressings on the rash, maintain hydration, seek advice if new vesicles form after 7 days of treatment or healing is delayed, and avoid contact with pregnant individuals, immunosuppressed individuals, and babies under 1 month old until all vesicles are crusted. After recovery, advise discussing shingles vaccination with their GP.

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