Shingles

❍ At a glance

• About 1 in 3 people develop shingles in their lifetime.¹ Antiviral treatment is most effective within 72 hours of rash onset - valaciclovir 1000 mg TDS for 7 days (preferred) or aciclovir 800 mg five times daily for 7 days. Starting after 72 hours is still worthwhile if new blisters are still forming, if the patient is older, or if the face is affected. Don't wait.
• Ophthalmic shingles (rash involving the tip of the nose, forehead, or periorbital area) and Ramsay Hunt syndrome (ear rash with ipsilateral facial weakness or hearing change) both require urgent same-day review - usually with ophthalmology or ENT input respectively. Permanent vision loss and facial palsy are preventable with prompt treatment.
• Post-herpetic neuralgia (PHN) affects approximately 10-15% of patients overall; rises to roughly 1 in 3 in patients aged 70 and over.¹ Management options include gabapentin, pregabalin, amitriptyline, duloxetine, and topical lidocaine or capsaicin patches. PHN can persist for months to years and is one of the strongest arguments for vaccination.
• Shingrix (recombinant, non-live): 97% efficacy in adults aged 50-69, 91% in those aged 70 and over, approximately 89-91% protection against PHN.⁴ Two doses, 2-6 months apart. Funded in NZ for age 65+ and immunocompromised adults aged 18+. Suitable for immunocompromised patients (unlike live Zostavax). Can be co-administered with influenza and COVID-19 booster.

❍ Patient information

This section is written in patient-friendly language and can be used as a basis for consultation or directed reading.

Shingles is caused by the varicella-zoster virus - the same virus that causes chickenpox. After a chickenpox infection, the virus goes dormant in nerve cells near the spinal cord and brain. Decades later, often prompted by a dip in immune function, it can reactivate as shingles. About one in three people will develop shingles at some point in their lifetime.¹ Most cases are unpleasant but manageable. Some cause lasting nerve pain that takes months or years to settle. A small number affect the eye or ear and require urgent attention. The good news is that there is now a highly effective vaccine.

What does shingles feel like? Shingles usually begins with a few days of pain, burning, or sensitivity in a specific area of skin, often before any rash appears. That pre-rash phase is easy to mistake for a muscle strain, a dental problem, or something else entirely. Then the rash arrives - it appears as a band or stripe on one side of the body, typically the chest, abdomen, or lower back, following the path of a single nerve. Occasionally it affects the face or scalp. The rash starts as red patches, then blisters, then crusts over about seven to ten days. The pain can be surprisingly intense - many people describe it as burning, stabbing, or electric.

When to see a doctor - and how quickly: antiviral treatment is most effective when started within 72 hours of the rash appearing. If you suspect shingles, aim to be seen within that window. Do not wait to see whether it settles on its own. There are situations that need urgent same-day attention: shingles near the eye (a rash involving the tip of the nose, the forehead, or the area around the eye may indicate ophthalmic shingles and puts vision at risk - this requires urgent review, usually with an ophthalmologist);² shingles affecting the ear (a rash around the ear combined with facial weakness on the same side or a change in hearing may indicate Ramsay Hunt syndrome, which involves the facial nerve);² shingles in anyone who is immunocompromised; and a rash that crosses the midline of the body, which suggests significant immune suppression.

Treatment: the main treatment is an antiviral - valaciclovir (1000 mg three times daily for seven days) is generally preferred because it is easier to take and achieves better drug levels in the body; aciclovir (800 mg five times daily for seven days) is an alternative.³ Starting after 72 hours is still worthwhile in some situations - particularly if new blisters are still forming, if you are older, or if the rash affects the face - so it is worth being seen even if that window has passed. Pain management matters: paracetamol, ibuprofen, and in some cases short-term opioids or nerve-calming medications such as gabapentin or amitriptyline can all be used. Your GP will tailor this to what is safe for you. While blisters are active, avoid close contact with pregnant people who have not had chickenpox, newborns, and people with a weakened immune system. Once blisters have fully crusted over, you are no longer contagious.

Post-herpetic neuralgia: the most common complication of shingles is post-herpetic neuralgia (PHN) - pain that persists in the area of the rash after the skin has healed. It occurs because the virus has damaged nerve fibres, and those fibres take time to recover - sometimes a long time, sometimes not fully. PHN affects roughly 10 to 15 percent of people who get shingles, but the risk rises sharply with age.¹ In people aged 70 and over, it may be closer to one in three. Treatment is possible - gabapentin, pregabalin, amitriptyline, duloxetine, and topical lidocaine or capsaicin patches can all reduce PHN pain - but it can be difficult to manage and may persist for months or years. This is one of the strongest reasons to get vaccinated before shingles ever strikes.

The Shingrix vaccine: Shingrix is a recombinant (non-live) shingles vaccine. It works by priming the immune system to respond strongly if the dormant varicella-zoster virus tries to reactivate. It is given as two injections, spaced two to six months apart, into the upper arm. In adults aged 50 to 69, Shingrix reduces the risk of developing shingles by around 97 percent.⁴ In adults aged 70 and over, efficacy is approximately 91 percent.⁴ Protection against post-herpetic neuralgia is similarly high - around 89 to 91 percent.⁴ Protection appears durable; studies following participants out to ten years have shown that efficacy remains high.⁵ Unlike the older live vaccine (Zostavax), Shingrix is suitable for people with a weakened immune system. People who have had shingles before can still benefit from Shingrix. People who previously received Zostavax should still receive Shingrix - it provides substantially better protection.

Funded status in New Zealand: as of 2026, Shingrix is funded for people aged 65 and over, and for immunocompromised adults aged 18 and over.⁶ For adults aged 50 to 64 who are not immunocompromised, the vaccine is available but involves an out-of-pocket cost. Funding schedules are reviewed periodically. If you are in a funded group, the vaccine is available through your GP or a Shingrix-stocking pharmacy at no charge. Side effects from Shingrix are common - soreness, redness, and swelling at the injection site, and systemic effects such as fatigue, muscle aches, headache, or low-grade fever affect roughly half of people after each dose and typically settle within two to three days.⁴ These reactions are more noticeable than those from many other adult vaccines; it is worth knowing this in advance so they are not alarming. Shingrix can be given at the same visit as other vaccines including influenza and COVID-19 booster.

Most New Zealanders aged over 40 are likely to have had chickenpox at some point, even if they do not remember. For practical purposes, most adults in this age group are assumed to have had prior exposure and are therefore eligible for the shingles vaccine. A blood test can confirm immunity if there is genuine doubt.