What are the red flags for shingles in urgent care?

Rash on the tip of the nose (Hutchinson’s sign), eye pain, red eye or reduced vision → Herpes zoster ophthalmicus — same-day ophthalmology; Facial weakness, ear vesicles, vertigo → Ramsay Hunt — ENT / antivirals; Immunosuppressed, disseminated rash → Specialist advice / possible IV aciclovir; Pregnant → Specialist advice

Which decision rule is used for shingles?

Who gets an antiviral (within 72 h of rash): Age over 50; Immunocompromised (any time); Ophthalmic involvement (any time); Moderate–severe pain or rash; Non-truncal rash (limbs, perineum, neck). Otherwise healthy, under 50 with mild truncal rash → antivirals optional.

What should I prescribe for shingles?

Aciclovir: 800 mg five times a day (7 days); Valaciclovir (alternative): 1 g three times a day (7 days); Paracetamol: 1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk) (As needed); Ibuprofen: 400 mg three times a day with food (3–5 days. Avoid: NSAID-sensitive asthma, GI bleed/ulcer, renal impairment, anticoagulants, heart failure, pregnancy)

Shingles: Antivirals & the Eye | Urgent Care Clinic

Q: What safety-netting advice should I give for shingles?

Advise the patient to return or seek help if: Any eye pain, redness or blurred vision; Facial weakness; Rash spreading widely or you feel very unwell; Rash becomes red, hot and painful (infection).

1Rule out first — red flags

If you find…	…then
Rash on the tip of the nose (Hutchinson’s sign), eye pain, red eye or reduced vision	Herpes zoster ophthalmicus — same-day ophthalmology
Facial weakness, ear vesicles, vertigo	Ramsay Hunt — ENT / antivirals
Immunosuppressed, disseminated rash	Specialist advice / possible IV aciclovir
Pregnant	Specialist advice

2Focused history

Onset of pain and rash (within 72 h?)
Distribution; eye or ear symptoms
Immunosuppression (chemo, steroids, HIV, transplant)
Pregnant contacts / neonates / immunosuppressed contacts

3Focused examination

Dermatomal vesicular rash not crossing the midline
Tip of nose, eye (acuity, redness)
Ears and facial nerve

4Decide — investigate only if it changes the plan

Who gets an antiviral (within 72 h of rash)

Age over 50
Immunocompromised (any time)
Ophthalmic involvement (any time)
Moderate–severe pain or rash
Non-truncal rash (limbs, perineum, neck)

Otherwise healthy, under 50 with mild truncal rash → antivirals optional.

Investigation	Only if…
None	Clinical diagnosis

5Treat & send home

Management & advice

Keep the rash clean, dry and covered; loose clothing
Infectious to those who haven’t had chickenpox until lesions crust (avoid pregnant women, newborns, immunosuppressed)
Work/school: can attend if rash covered (avoid if weeping on exposed areas)

Refer / follow-up

Ophthalmic → ophthalmology same day
Severe post-herpetic neuralgia → GP (amitriptyline / pregabalin options)

℞

Discharge prescription (TTO)Typical adult doses — check the BNF/BNFc, allergies, renal function, pregnancy and interactions.

Drug	Dose	Duration / notes
Aciclovir	800 mg five times a day	7 days
Valaciclovir (alternative)	1 g three times a day	7 days
Paracetamol	1 g every 4–6 hours, max 4 g in 24 h (reduce if under 50 kg or liver risk)	As needed
Ibuprofen	400 mg three times a day with food	3–5 days. Avoid: NSAID-sensitive asthma, GI bleed/ulcer, renal impairment, anticoagulants, heart failure, pregnancy

6Safety-net

Say it like this

This is shingles. The antiviral tablets work best started early, so begin today, five times a day for a week. The rash is catching for anyone who hasn’t had chickenpox until it crusts over, so keep it covered and avoid pregnant women and newborns. Come back the same day if you get any eye pain, redness or blurred vision.

Come back / call 111 — or 999 if severe — if:

Any eye pain, redness or blurred vision
Facial weakness
Rash spreading widely or you feel very unwell
Rash becomes red, hot and painful (infection)

7Patient leaflets — scan & go

Official NHS pages. Ask the patient to scan the code with their phone camera, or tap “Show to patient” to make it full screen.

Shinglesnhs.uk/conditions/shingles

8Document

Shingles — clinic note

A structure to document efficiently. It is not a completeness check — use your trust’s system and your clinical judgement.

URGENT CARE — SHINGLES PRESENTING COMPLAINT: HISTORY Onset of pain and rash (within 72 h?): Distribution; eye or ear symptoms: Immunosuppression (chemo, steroids, HIV, transplant): Pregnant contacts / neonates / immunosuppressed contacts: RED FLAGS (record present / absent) [ ] Rash on the tip of the nose (Hutchinson’s sign), eye pain, red eye or reduced vision [ ] Facial weakness, ear vesicles, vertigo [ ] Immunosuppressed, disseminated rash [ ] Pregnant PMH: DRUG HISTORY: ALLERGIES: SOCIAL (job / who is at home / driving): OBSERVATIONS: RR SpO2 HR BP Temp (NEWS2 ) EXAMINATION Dermatomal vesicular rash not crossing the midline: Tip of nose, eye (acuity, redness): Ears and facial nerve: DECISION RULE — Who gets an antiviral (within 72 h of rash): result ______ INVESTIGATIONS: none required / None — result: IMPRESSION: PLAN Treatment / TTO (drug, dose, duration): Advice given: Leaflet given (QR / printed): Shingles Follow-up / referral: SAFETY-NETTING (told to return / call 111 / 999 if): - Any eye pain, redness or blurred vision - Facial weakness - Rash spreading widely or you feel very unwell - Rash becomes red, hot and painful (infection) Patient understands and agrees with the plan: Y / N Seen by: Grade: Date/Time:

✓Guidelines

NICE CKS — Shingles

Doses are typical adult doses drawn from the guidance above. Always check the current BNF/BNFc and your local antimicrobial policy.

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