Dawaa Reference

infectious

Herpes zoster (shingles)

Treatment options, dosing, cautions and Egyptian brands from the shipped Dawaa Reference card.

Evidence status

Checked against the sources named below

Sources6 sources

Egyptian National Drug Formulary - Antimicrobial 2023 (valacyclovir monograph) · MSF Essential Drugs 2024 - paracetamol (oral) · Ibuprofen 100 mg/5 ml SmPC section 4.2 (eMC product 4560) · Amitriptyline Hydrochloride 25 mg Film-Coated Tablets SmPC sections 4.1 and 4.2 (eMC product 13683) · Egyptian National Drug Formulary - Nervous system disorders 2025 (gabapentin monograph) · Egyptian National Drug Formulary - Antimicrobial 2023 (famciclovir monograph)

Verified against6 documents
  • Egyptian National Drug Formulary - Antimicrobial 2023 (valacyclovir monograph)
  • MSF Essential Drugs 2024 - paracetamol (oral)
  • Ibuprofen 100 mg/5 ml SmPC section 4.2 (eMC product 4560)
  • Amitriptyline Hydrochloride 25 mg Film-Coated Tablets SmPC sections 4.1 and 4.2 (eMC product 13683)
  • Egyptian National Drug Formulary - Nervous system disorders 2025 (gabapentin monograph)
  • Herpes Zoster - disease-level clinical article (herpes-zoster-full.txt)

Verified date2026-08

Presentation reference

Is it this?

Reference only, to read alongside your own examination.

Symptoms — what the patient reports (7)

  • Zoster begins with a prodrome of fever, malaise, and severe burning pain before any rash appears [burning pain · fever · malaise · rash]
  • Abnormal skin sensations or pain in the affected area can start at least 48 hours before any lesion is visible
  • Headache, general malaise, and light sensitivity can accompany the pre-rash phase [headache · malaise · photophobia · rash]
  • Pain during the blistering phase is often severe and does not respond well to standard pain medication
  • Pain persisting beyond 4 weeks marks chronic infection, with tingling and shock-like sensations that can last a year or more [shock · tingling]
  • Spread from the facial nerve to the inner-ear nerve causes hearing loss and vertigo in Ramsay Hunt syndrome [hearing loss · vertigo]
  • Radicular pain along a dermatome with no rash at all defines zoster sine herpete

Signs — what you find (8)

  • Lesions stay confined to one side, within a single dermatome
  • The thoracic, cervical, trigeminal, and lumbosacral dermatomes are most often involved, in that order
  • Lesions start as closely grouped red bumps that quickly turn into blisters on a red, swollen base [blisters]
  • Vesicles on the tip or side of the nose flag involvement of the nerve branch that also supplies the eye [blisters · vesicles]
  • Eye involvement occurs in roughly 10 to 25 percent of cases, with keratitis, uveitis, or optic nerve palsy [paralysis]
  • More than 20 skin lesions outside the original area define disseminated zoster, which can also affect other organs and turn lethal [skin lesions]
  • Pain persisting 3 months after the rash defines post-herpetic neuralgia, most often when the eye-nerve branch is involved in older adults [neuralgia · rash]
  • Risk factors for lasting nerve pain include older age, severe early or acute pain, a severe rash, and a weakened immune system [neuralgia · rash]

Tests (6)

  • Diagnosis rests on the burning pain plus the characteristic look and spread of the rash
  • A red background on dermatoscopy is seen in essentially all cases of zoster
  • Dermatoscopy can diagnose zoster about 1.6 days earlier than clinical examination alone
  • A halo sign on dermatoscopy comes from the contrast between crusted vesicle centres and the surrounding redness
  • A Tzanck smear of vesicle fluid shows multinucleated giant cells but is less sensitive and specific than PCR or antibody testing
  • Newer real-time PCR is faster and less prone to contamination than the older nested PCR or viral culture

If not this — what else fits (12)

  • Pain before any rash can mimic gallbladder disease or biliary colic
  • Pre-rash pain can also be mistaken for renal colic, trigeminal neuralgia, or a dental infection
  • Prodromal pain is often mistaken for a toothache, leading to unnecessary dental treatment
  • Zoster in the mouth involves only one side, unlike other blistering oral conditions
  • Herpes zoster skin lesions must be differentiated from chickenpox
  • Herpes zoster skin lesions must be differentiated from herpes simplex
  • Herpes zoster skin lesions must be differentiated from cellulitis
  • Herpes zoster skin lesions must be differentiated from erysipelas
  • Herpes zoster skin lesions must be differentiated from folliculitis
  • Herpes zoster skin lesions must be differentiated from irritant contact dermatitis
  • Herpes zoster skin lesions must be differentiated from insect bites
  • Herpes zoster skin lesions must be differentiated from mucosal candidiasis

SourceStatPearls "Herpes Zoster" - disease-level clinical article

Presentation findings are traced to the source above.

Rx: Antiviral | Main treatment | Antiviral - for acyclovir-resistant zoster | Pain - first step | Pain - add if not enough | Nerve pain

ANTIVIRAL - choose one

1

ACYCLOVIR

Antiviral

1st line

Strength800 mg

Formoral.solid

Adult dose and duration

800 mg orally 5 times daily (every 4 hours while awake) x 7 days

Paediatric dose

20 mg/kg/dose [child max 800 mg]

(20 mg/kg 4 times daily (max 800 mg/dose) for children 1 mo–11 yrs; 800 mg 5 times daily for adolescents ≥12 yrs)

Dose by weight
3kg60 mg/dose
4kg80 mg/dose
5kg100 mg/dose
6kg120 mg/dose
7kg140 mg/dose
8kg160 mg/dose
9kg180 mg/dose
10kg200 mg/dose
11kg220 mg/dose
12kg240 mg/dose
13kg260 mg/dose
14kg280 mg/dose
15kg300 mg/dose
16kg320 mg/dose
17kg340 mg/dose
18kg360 mg/dose
19kg380 mg/dose
20kg400 mg/dose
21kg420 mg/dose
22kg440 mg/dose
23kg460 mg/dose
24kg480 mg/dose
25kg500 mg/dose
26kg520 mg/dose
27kg540 mg/dose
28kg560 mg/dose
29kg580 mg/dose
30kg600 mg/dose
31kg620 mg/dose
32kg640 mg/dose
33kg660 mg/dose
34kg680 mg/dose
35kg700 mg/dose
36kg720 mg/dose
37kg740 mg/dose
38kg760 mg/dose
39kg780 mg/dose
40kg800 mg/dose
41kg800 mg/dose (capped)
42kg800 mg/dose (capped)
43kg800 mg/dose (capped)
44kg800 mg/dose (capped)
45kg800 mg/dose (capped)
46kg800 mg/dose (capped)
47kg800 mg/dose (capped)
48kg800 mg/dose (capped)
49kg800 mg/dose (capped)
50kg800 mg/dose (capped)
Dose source

Egyptian National Drug Formulary - Antimicrobial 2023

Why

Nucleoside analogue antiviral that inhibits viral DNA polymerase to limit replication of varicella-zoster virus; started early after the shingles rash appears, before extensive viral replication, to reduce the severity of the episode.

Cautions
  • Initiate within 72 hours of rash onset for optimal efficacy.
  • Maintain high fluid intake to prevent renal crystallization.
  • Dose adjustment is required in renal impairment.
Egyptian brands
Egyptian brandManufacturerIndicative price
VIRUSTAT 800MG 35 TAB.PHAROPHARMA266.00 EGP (7.60/unit)
ACIVIRAX 800MG 20 TABS.MASH PREMIERE154.00 EGP (7.70/unit)
LOVIR 800 MG 35 ORAL DISP. TABS.SUN PHARMA EGYPT LIMITED300.00 EGP
BORGAVIRAX 200MG/5ML SUSP. 125 ML? strength differs? different route - not oral solidBORG61.00 EGP
VIRUSTAT 200MG/5ML SUSP. 120 ML? strength differs? different route - not oral solidPHAROPHARMA61.00 EGP
2

VALACYCLOVIR

Antiviral

1st line

Strength500 mg

Formoral.solid

Adult dose and duration

1000 mg three times daily x 7 days

Paediatric dose

The formulary gives no paediatric herpes zoster dose for valacyclovir - its paediatric doses are for herpes labialis and genital herpes. Use the aciclovir row in a child.

Choice

Alternatives. Three doses a day against aciclovir's five. Shingles is painful and its patients are old; a five-times-a-day schedule is the one that gets missed.

Dose source

Egyptian National Drug Formulary - Antimicrobial 2023 (valacyclovir monograph)

Why

Three doses a day against aciclovir's five. Shingles is painful, patients are elderly, and a five-times-a-day schedule is the one they miss. The formulary carries the drug and the herpes zoster dose, and it is on the Egyptian Essential Medicine List.

Cautions
  • An alternative to the aciclovir above, not an addition. Give one antiviral.
  • Start within 72 hours of the rash appearing - the formulary states efficacy is not established beyond that, and preferably within 48 hours.
  • Reduce the dose in renal impairment: 1 g every 12 hours if creatinine clearance is 30-49, every 24 hours if 10-29, and 500 mg every 24 hours below 10.
  • Keep fluid intake up.
  • Confusion and hallucination occur in the elderly and in renal impairment, and are usually a sign the dose is too high.
Egyptian brands
Egyptian brandManufacturerIndicative price
VIROCLEAR 500 MG 10 TAB.ALFACURE PHARMACEUTICALS50.00 EGP (5.00/unit)
VALTREX 500 MG 42 TAB.GLAXO SMITHKLINE789.00 EGP (18.79/unit)
HERPACUT 500 MG 10 SCORED F.C. TABS.INTERNATIONAL DRUG AGENCY (IDI)50.00 EGP
VALYSERNEX 500MG 20 F.C. CAPLETEVA PHARMA154.00 EGP

MAIN TREATMENT

3

REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)

1st line
Dose source

Herpes Zoster - disease-level clinical article (herpes-zoster-full.txt)

Why

Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen.

Cautions
  • RED FLAG - Prompt ophthalmology referral is needed when eye involvement is present.

ANTIVIRAL - FOR ACYCLOVIR-RESISTANT ZOSTER

4

FAMCICLOVIR

Antiviral - for acyclovir-resistant zoster

1st line

Strength500 mg

Formoral.solid

Adult dose and duration

500 mg every 8 hours x 7 days

Paediatric dose

The formulary gives no paediatric dose for herpes zoster in immunocompetent children; its paediatric famciclovir doses are for genital herpes and for HIV-positive adolescents.

Dose source

Egyptian National Drug Formulary - Antimicrobial 2023 (famciclovir monograph) - verbatim: "Herpes zoster (shingles): Oral: Note: Initiate therapy as soon as possible after diagnosis and within 1 week of rash onset or any time before full crusting of lesions. Immunocompetent patients: 500 mg every 8 hours for 7 days."

Why

The card carries acyclovir and valacyclovir and stops there. Famciclovir is the third oral antiviral licensed for shingles, the formulary gives it a zoster heading of its own, and the article names it for the patient whose virus is acyclovir-resistant.

Cautions
  • Start it within the first week of the rash, or at least before the lesions have fully crusted - after that an antiviral has little left to offer.
  • Reduce the dose in renal impairment; the formulary steps it down as creatinine clearance falls, and again for dialysis patients.
  • This dose is for the immunocompetent patient - shingles in someone immunosuppressed needs a different plan and usually a specialist.
  • It does not prevent post-herpetic neuralgia on its own; the pain rows on the card still apply.
Egyptian brands
Egyptian brandManufacturerIndicative price
EACLOVIR 500MG 7 F.C. TABS.MEDIZEN PHARMACEUTICAL INDUSTRIES > EGYPTIAN AMERICAN85.00 EGP (12.14/unit)
PROPENCIVIR 500MG 7 F.C. TAB.BIORIGINAL INTERNATIONAL GROUP PHARMA175.50 EGP (25.07/unit)

PAIN - FIRST STEP - give alongside

5

PARACETAMOL

Pain - first step

add-on - not a substitute

Strength500 mg

Formoral.solid

Adult dose and duration

1000 mg three or four times daily, maximum 4000 mg in 24 hours - while the rash is painful, usually 2-4 weeks

Paediatric dose

15 mg/kg/dose [child max 500 mg]

(15 mg/kg 3 or 4 times daily, maximum 60 mg/kg daily. Under 1 month: 10 mg/kg 3 or 4 times daily, maximum 40 mg/kg/day (MSF Essential Drugs 2024).)

Dose by weight
3kg45 mg/dose
4kg60 mg/dose
5kg75 mg/dose
6kg90 mg/dose
7kg105 mg/dose
8kg120 mg/dose
9kg135 mg/dose
10kg150 mg/dose
11kg165 mg/dose
12kg180 mg/dose
13kg195 mg/dose
14kg210 mg/dose
15kg225 mg/dose
16kg240 mg/dose
17kg255 mg/dose
18kg270 mg/dose
19kg285 mg/dose
20kg300 mg/dose
21kg315 mg/dose
22kg330 mg/dose
23kg345 mg/dose
24kg360 mg/dose
25kg375 mg/dose
26kg390 mg/dose
27kg405 mg/dose
28kg420 mg/dose
29kg435 mg/dose
30kg450 mg/dose
31kg465 mg/dose
32kg480 mg/dose
33kg495 mg/dose
34kg500 mg/dose (capped)
35kg500 mg/dose (capped)
36kg500 mg/dose (capped)
37kg500 mg/dose (capped)
38kg500 mg/dose (capped)
39kg500 mg/dose (capped)
40kg500 mg/dose (capped)
41kg500 mg/dose (capped)
42kg500 mg/dose (capped)
43kg500 mg/dose (capped)
44kg500 mg/dose (capped)
45kg500 mg/dose (capped)
46kg500 mg/dose (capped)
47kg500 mg/dose (capped)
48kg500 mg/dose (capped)
49kg500 mg/dose (capped)
50kg500 mg/dose (capped)
Dose source

MSF Essential Drugs 2024 - paracetamol (oral)

Why

The pain is what the patient came with. The antiviral shortens the rash; it does very little for today's pain. Uncontrolled acute zoster pain is also the strongest predictor of post-herpetic neuralgia, so treating it is not just comfort.

Cautions
  • Regular, not as-needed. Zoster pain is constant for the first week or two and PRN dosing under-treats it.
  • Check every other product for paracetamol - cold and flu sachets are the usual route to an accidental overdose.
  • Reduce the maximum to 3000 mg/day if the patient is under 50 kg, malnourished, or has liver disease.
  • If paracetamol and an NSAID together are not holding the pain, that is the point to add a nerve-pain drug, not to keep escalating the analgesic.
  • 500 mg is the per-dose ceiling used here for a child. 1000 mg is the adult dose and does not belong in a weight calculation - the daily 60 mg/kg limit is the one that binds first in any case.
Egyptian brands
Egyptian brandManufacturerIndicative price
FEBRIMOL 500 MG 20 TAB.PHARCO3.50 EGP (0.17/unit)
CETAMOL 500 MG 20 TABS.MEMPHIS8.00 EGP (0.40/unit)
PARACETAMOL-MUP 500MG B.P. 20 TABS.MUP13.00 EGP (0.65/unit)
CETAL 500 MG 20 TABS.EIPICO24.00 EGP (1.20/unit)
ARKADOLOW 500 MG 30 F.C. TABS.UTOPIA42.00 EGP (1.40/unit)
PARAMOL 500MG 20 TAB.MISR38.00 EGP (1.90/unit)
ADOL 500MG 24 CAPLETSJULPHAR32.00 EGP
AUGICETAMIDE 500 MG 20 SACHETSAUG PHARMA50.00 EGP
FEBRIMOL ORAL DROPS 20 ML? strength differs? different route - not oral solidPHARCO4.00 EGP
THERA-LO 3.2G/100ML ORAL SUSP. 100 ML? strength differs? different route - not oral solidPHAROPHARMA5.00 EGP

PAIN - ADD IF NOT ENOUGH - give alongside

6

IBUPROFEN

Pain - add if not enough

add-on - not a substitute

Strength400 mg

Formoral.solid

Adult dose and duration

400 mg up to three times daily with or after food, maximum 1200 mg in 24 hours - while the rash is painful, usually 2-4 weeks

Paediatric dose

20 mg/kg/day [child max 1200 mg]

(20 mg/kg/day in divided doses, with food. Not under 3 months. Shingles in a child is uncommon and warrants a look for immunosuppression.)

Dose by weight
3kg60 mg/day
4kg80 mg/day
5kg100 mg/day
6kg120 mg/day
7kg140 mg/day
8kg160 mg/day
9kg180 mg/day
10kg200 mg/day
11kg220 mg/day
12kg240 mg/day
13kg260 mg/day
14kg280 mg/day
15kg300 mg/day
16kg320 mg/day
17kg340 mg/day
18kg360 mg/day
19kg380 mg/day
20kg400 mg/day
21kg420 mg/day
22kg440 mg/day
23kg460 mg/day
24kg480 mg/day
25kg500 mg/day
26kg520 mg/day
27kg540 mg/day
28kg560 mg/day
29kg580 mg/day
30kg600 mg/day
31kg620 mg/day
32kg640 mg/day
33kg660 mg/day
34kg680 mg/day
35kg700 mg/day
36kg720 mg/day
37kg740 mg/day
38kg760 mg/day
39kg780 mg/day
40kg800 mg/day
41kg820 mg/day
42kg840 mg/day
43kg860 mg/day
44kg880 mg/day
45kg900 mg/day
46kg920 mg/day
47kg940 mg/day
48kg960 mg/day
49kg980 mg/day
50kg1000 mg/day
Dose source

Ibuprofen 100 mg/5 ml SmPC section 4.2 (eMC product 4560)

Why

Can be given with the paracetamol when that alone is not enough. AAFP names NSAIDs alongside acetaminophen for the acute pain.

Cautions
  • SHINGLES IS NOT CHICKENPOX. The rule against NSAIDs in varicella is about primary chickenpox and the risk of necrotising soft tissue infection; AAFP names NSAIDs for zoster in adults. If the diagnosis is actually primary varicella, do not give this.
  • Avoid in asthma, active peptic ulcer, significant renal impairment, heart failure, and the third trimester.
  • Most zoster patients are elderly - check the eGFR and check whether they are already on an ACE inhibitor or a diuretic before adding an NSAID.
  • With food, short course, and not on top of another NSAID.
Egyptian brands
Egyptian brandManufacturerIndicative price
DAJUANOFEN 400 MG 20 F.C. TABS.COPAD PHARMA5.00 EGP (0.25/unit)
FLABU 400MG 10 F.C.TAB.DELTA PHARMA3.75 EGP (0.38/unit)
NOVA-PROFEN 400MG 30 F.C. TABLETSSANOFI12.75 EGP (0.42/unit)
IBUPROFEN 400 MG 10 TAB.SEDICO6.00 EGP (0.60/unit)
MAFO 400 MG 30 F.C.TABSEIPICO42.00 EGP (1.40/unit)
BRUFEN 400 MG 30 TABS.KAHIRA > ABBOTT LABORATORIES78.00 EGP (2.60/unit)
PROFUSOL 400MG 20 S.G CAPS.EUROPEAN EGYPTIAN PHARM. IND.31.00 EGP
ANALGIPROF 400 MG 25 SACHETSEVA PHARMA37.50 EGP
NOVA-PROFEN 100MG/5ML ORAL SUSP. 100ML? strength differs? different route - not oral solidSANOFI2.25 EGP
BRUFEMOL-N SUSP. 60 ML? strength differs? different route - not oral solidARAB DRUG COMPANY (ADCO)4.50 EGP

NERVE PAIN - give alongside

7

AMITRIPTYLINE

Nerve pain

add-on - not a substitute

Strength25 mg

Formoral.solid

Adult dose and duration

10-25 mg in the evening to start, increased by 10-25 mg every 3-7 days as tolerated; usual range 25-75 mg at night - reviewed at 4-6 weeks; continue while it is helping, then taper

Paediatric dose

The label states amitriptyline should not be used in children and adolescents under 18 years, as safety and efficacy have not been established.

Choice

Alternatives. NICE CG173 offers a free choice of four drugs for neuropathic pain; amitriptyline is the cheapest to start and the most familiar in primary care.

Dose source

Amitriptyline Hydrochloride 25 mg Film-Coated Tablets SmPC sections 4.1 and 4.2 (eMC product 13683)

Why

Post-herpetic neuralgia is neuropathic pain and NICE CG173 offers a choice of four drugs for it. Amitriptyline is the cheapest of the four in Egypt and is licensed for the indication. This is the drug the patient needs when the rash has healed and the pain has not.

Cautions
  • Dry mouth, constipation, urinary retention, postural dizziness and falls are all dose-related.
  • Alternative to the gabapentin below, not an addition. NICE offers a choice of one.
  • Take it in the evening; the sedation is useful when the pain is worst at night.
  • Avoid after a recent myocardial infarction, in arrhythmia, and in untreated closed-angle glaucoma.
  • It takes 2-4 weeks at an adequate dose to work. Stopping at day 5 because 'it did nothing' is the commonest way this fails.
  • Do not stop abruptly after a long course - taper.
  • Avoid in elderly patients, and in severe cardiovascular disease or arrhythmias. Amitriptyline - StatPearls - NCBI Bookshelf (NBK537225) puts amitriptyline on the American Geriatrics Society's Beers list, to be avoided in the elderly because its anticholinergic effect is so strong.
Egyptian brands
Egyptian brandManufacturerIndicative price
TRYPTIZOL 25 MG 30 TABS.KAHIRA33.00 EGP (1.10/unit)
GRANITYLLIN 25MG/5ML SYP. 120 ML? strength differs? different route - not oral solidGRAND PHARMA > DELTA GRAND PHARMA5.00 EGP
ZINOTRAVAL 25MG/5ML SYP. 120 ML? strength differs? different route - not oral solidDEBEIKY > PHARMACHEMIC10.00 EGP
8

GABAPENTIN

Nerve pain

add-on - not a substitute

Strength300 mg

Formoral.solid

Adult dose and duration

300 mg on day 1, 300 mg twice daily on day 2, 300 mg three times daily on day 3, then increased in 300 mg/day steps every 2-3 days to a usual 1800 mg/day in three divided doses - titrated over 1-3 weeks; reviewed at 4-6 weeks and continued while it is helping

Paediatric dose

The paediatric mg/kg dose in the formulary is for partial-onset seizures from 3 years, not for neuropathic pain. The neuropathic pain indication is adults only, and the dose is a step-up schedule rather than a single mg/kg rule.

Dose source

Egyptian National Drug Formulary - Nervous system disorders 2025 (gabapentin monograph)

Why

The formulary names post-herpetic neuralgia in the indication line, with its own titration schedule. NICE CG173 offers it as one of four initial choices for neuropathic pain.

Cautions
  • Alternative to the amitriptyline above, not an addition. NICE offers a choice of one.
  • It must be titrated. A patient started straight on 300 mg three times daily will be too drowsy to continue.
  • Reduce the dose in renal impairment - gabapentin is cleared by the kidney and accumulates.
  • Drowsiness, dizziness and unsteadiness are common early and matter in an elderly patient who may fall.
  • Divide into three doses with no more than 12 hours between them.
  • Do not stop abruptly - taper over at least a week.
Egyptian brands
Egyptian brandManufacturerIndicative price
EZAPENTIN 300MG 10 CAPS.MULTI-APEX11.00 EGP (1.10/unit)
PENTALIPSY 300MG 10 CAPS.SAFE PHARMA14.40 EGP (1.44/unit)
OCTOCONVAL 300 MG 30 CAPS.OCTOBER PHARMA72.00 EGP (2.40/unit)
NEUROGLOPENTIN 300 MG 30 CAPS.GLOBAL NAPI PHARMACEUTICALS111.00 EGP (3.70/unit)
SHALGATEN 300MG 30 CAPS.EGPI > MASH PREMIERE126.00 EGP (4.20/unit)
GABALEPSY 300MG 30 CAPS.EL-OBOUR135.00 EGP (4.50/unit)
GABAVERONA 300 MG 30 H.G. CAPS.AVERROES PHARMA126.00 EGP
SAJALIPSY 300 MG 30 H.G. CAPS.SAJA PHARMACEUTICALS126.00 EGP
STABLENTIN 6MG/120ML SYRUP? strength differs? different route - not oral solidMEPACO21.60 EGP
ADAPTAN 250MG/5ML ORAL SOLUTION 100 ML? strength differs? different route - not oral solidEUROPEAN EGYPTIAN PHARM. IND.37.00 EGP

Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy.