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Multidisciplinary approach to patient care

Although many patients with shingles will likely be managed in primary care by their general practitioners, some patients may require a variety of medical specialists to be involved in their care.1,2

Identifying patients who need specialist care

Several factors may indicate a need for referral for specialist care or immediate medical attention:1,2

Examples of factors that require referral to a specialist

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Refer patients or seek specialist advice if:

  • New vesicles are forming after 7 days of oral antiviral treatment (which increases the suspicion of an underlying immunodeficiency syndrome)
  • Healing of lesions is delayed
  • Pain is inadequately controlled by oral analgesia
  • Pain may require a strong opioid
  • Pain persists after the resolution of skin lesions
  • Shingles recurs in a patient who is immunocompromised (as specific approaches to management/prophylaxis may be needed)
  • A patient who is thought to be immunocompetent has had two episodes of shingles (as underlying immunocompromised status may need to be excluded)

Examples of factors that indicate a medical emergency

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Admit to hospital or seek immediate specialist advice if:

  • Serious complications such as meningitis, encephalitis or myelitis are suspected
  • Shingles occurs in the ophthalmic distribution of the trigeminal nerve, which puts patients at risk of ocular complications
  • The patient is severely immunocompromised
  • The patient is immunocompromised and has a severe or widespread rash, or is systemically unwell
  • The patient is a child who is immunocompromised

Identifying the specialists who can offer support

Healthcare professionals from a range of disciplines may be involved in patient care.1-4 The National Institute for Health and Care Excellence recommends using clinical judgement to decide who to consult or refer to, and the urgency, depending on the risk to the patient and the patient’s clinical condition.2

Ophthalmology

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Ophthalmologists may support, for example, patients with Hutchinson’s sign and patients with at least one obvious ocular symptom (e.g. ocular redness or pain, or blurred vision) even if shingles occurred several weeks previously, as inflammatory complications are frequently delayed1-4

Pain management

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Pain specialists may support, for example, patients with persistent or inadequately controlled pain1,2,4

Dermatology

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Dermatologists may support, for example, patients with complications such as bacterial skin infections or those who have existing skin conditions1,2

Clinical immunology

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Specialists in immunology can support patients with recurrence of shingles who may require testing for underlying immune deficiencies1,2

Otorhinolaryngology (Ear, nose and throat services)

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Otorhinolaryngologists may support patients with shingles oticus, especially if facial or auditory nerves are involved, or severe pain or cranial nerve palsies, due to the risk of severe complications3,4

Neurology

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Neurologists support in cases of acute focal neurological dysfunction or patients with other neurological signs and symptoms1,3

Obstetrics

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Obstetricians may support, for example, pregnant patients with shingles or those without a history of chickenpox who have been in contact with someone with shingles2

References

  1. Johnson RW et al. Herpes zoster epidemiology, management, and disease and economic burden in Europe: A multidisciplinary perspective. Ther Adv Vaccines 2015;3:109-120.
  2. National Institute for Health and Care Excellence. Clinical knowledge summary: Shingles. https://cks.nice.org.uk/topics/shingles/ (accessed February 2024).
  3. Werner RN et al. European consensus-based (S2k) guideline on the management of herpes zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 1: Diagnosis. J Eur Acad Dermatol Venereol 2017;31:9-19.
  4. Werner RN et al. European consensus-based (S2k) guideline on the management of herpes zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 2: Treatment. J Eur Acad Dermatol Venereol 2017;31:20-29.

Adverse events should be reported. Reporting forms and information can be found at https://yellowcard.mhra.gov.uk/. Adverse events should also be reported to GlaxoSmithKline on 0800 221 441.

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July 2024 | NP-GB-HZU-WCNT-240017 (V1.0)