Cold sores, genital herpes, and shingles: the AU general practice guide

Two viruses, many presentations

Two related but distinct viruses account for some of the most common infectious conditions managed in Australian general practice.

Herpes simplex virus (HSV) exists as two types. HSV-1 seroprevalence is approximately 70% in Australian adults, predominantly causing orolabial infection (cold sores) but increasingly causing genital herpes via oral-genital contact. HSV-2 seroprevalence is around 10–15%, with women more frequently affected than men (2:1), and genital herpes is the most common cause of genital ulceration in Australia. Both types establish lifelong latency in sensory ganglia after primary infection. Reactivation is triggered by stress, febrile illness, UV light, menstruation, and immunosuppression. Critically, asymptomatic viral shedding is common — transmission occurs without visible lesions.

Herpes zoster (shingles) is reactivation of varicella zoster virus (VZV) from dorsal root ganglia latency. The lifetime risk is approximately 30% in Australians, with roughly 140,000 cases per year. Incidence rises sharply with age (immunosenescence) and immunosuppression. The principal morbidity beyond the acute rash is post-herpetic neuralgia (PHN) — persistent neuropathic pain lasting more than 90 days after rash onset — affecting 10–20% of zoster patients overall and up to 50% of those over 80.

Both conditions are substantially preventable or modifiable: antiviral therapy reduces severity, and the Shingrix vaccine provides over 97% protection against zoster and is NIP-funded for eligible Australians.

A. Core clinical — the AU general-practice framework

Herpes simplex — diagnosis

HSV diagnosis is primarily clinical for typical presentations. HSV PCR swab of an active lesion is the gold standard when confirmation is needed — it differentiates HSV-1 from HSV-2 and is more sensitive than viral culture. In Australia, MBS item 69384 covers HSV PCR from an active mucosal or cutaneous lesion.

Type-specific HSV serology (IgG) has a limited role: it is appropriate for asymptomatic partner counselling in a serodiscordant couple, for ruling out primary versus recurrent infection in pregnancy, or in specific sexual health contexts. It is not a routine diagnostic tool — false-positive rates are significant and interpretation requires careful clinical context.

Offer HIV testing with every new HSV diagnosis. HSV can be an indicator infection for HIV and the two conditions frequently coexist.

Clinical history in HSV:

• Primary vs recurrent episode (primary is often more severe with systemic features, adenopathy, and prolonged lesion duration)
• Lesion location, prodrome (tingling, burning before lesion appears), frequency of recurrences
• Sexual history, partners, prior STI testing
• Atopic dermatitis (risk of eczema herpeticum)
• Pregnancy status and gestational age
• Immunocompromise — biologics, chemotherapy, HIV, corticosteroids

Herpes simplex — management

Per eTG: Herpes virus infections and Australian Medicines Handbook (AMH):

Primary genital herpes:

• Valaciclovir 500 mg twice daily × 7–10 days (preferred — twice-daily dosing supports adherence over the full course)
• Famciclovir 250 mg three times daily × 5 days
• Aciclovir 400 mg three times daily × 7–10 days
• Symptomatic support: topical lignocaine 5% gel for dysuria, sitz baths, simple analgesia
• Counsel regarding partner notification, transmission risk with and without lesions, condom use (reduces but does not eliminate transmission), asymptomatic shedding, and stigma reduction — ASHM provides excellent patient-facing resources

Recurrent genital herpes — patient-initiated episodic treatment: Treatment is most effective when started at the prodrome or first sign of recurrence:

• Valaciclovir 500 mg twice daily × 3 days
• Famciclovir 1 g twice daily × 1 day (single-day regimen)
• Aciclovir 400 mg three times daily × 5 days

Suppressive therapy (six or more recurrences per year, severe episodes, or transmission concern in serodiscordant couples):

• Valaciclovir 500 mg daily; 1 g daily when the primary goal is reducing transmission to an uninfected partner
• Famciclovir 250 mg twice daily or aciclovir 400 mg twice daily as alternatives
• Review annually; trial treatment cessation periodically to reassess whether suppression remains needed

Cold sores (HSV-1 orolabial):

• Topical aciclovir 5% or penciclovir 1% cream — apply at first prodrome; modest benefit when started early
• Oral valaciclovir 2 g twice daily × 1 day for severe or frequently recurring cold sores
• Suppressive valaciclovir 500 mg daily for very frequent recurrences affecting quality of life
• Daily SPF lip balm to reduce UV-triggered reactivation

Herpes zoster — diagnosis and management

Shingles is usually a clinical diagnosis. The presentation follows a characteristic sequence: prodromal neuropathic pain 1–4 days before rash, followed by a vesicular rash in a single dermatomal distribution that does not cross the midline. Thoracic dermatomes are involved in over 50% of cases, followed by cervical, lumbar, and trigeminal distributions. VZV PCR swab confirms atypical or disseminated presentations.

Antiviral treatment within 72 hours of rash onset reduces acute pain severity, shortens rash duration, and lowers PHN risk. Per eTG:

• Valaciclovir 1 g three times daily × 7 days (preferred — three-times-daily dosing is the best balance of compliance and pharmacokinetics)
• Famciclovir 250–500 mg three times daily × 7 days
• Aciclovir 800 mg five times daily × 7 days

Renal dose adjustment is mandatory for all three agents based on eGFR. Treatment beyond 72 hours remains appropriate for ophthalmic zoster and immunocompromised patients.

Pain management in acute zoster:

• Paracetamol 1 g four times daily ± NSAID (if no contraindication)
• Gabapentin — Authority Required under PBS for neuropathic pain; SafeScript/RTPM monitored; start 100–300 mg at night, titrate to 300 mg three times daily; renal dose adjust
• Pregabalin — Authority Required; start 25–75 mg twice daily, titrate to 150–300 mg twice daily; renal dose adjust
• Amitriptyline 10–25 mg at night — useful for sleep disruption from neuropathic pain
• Short-term tramadol or oxycodone for severe acute pain, with close monitoring
• Topical lignocaine 5% patch (Versatis) — PBS Authority for refractory PHN

Systemic corticosteroid added to antiviral therapy is not recommended routinely for uncomplicated acute zoster. It offers modest acute pain benefit but does not reduce PHN risk and introduces immunosuppressive risk. Reserve for Ramsay Hunt syndrome and severe ophthalmic zoster, as a specialist decision.

Post-herpetic neuralgia:

• First-line: gabapentin or pregabalin, titrated to the maximum tolerated effective dose
• Adjuncts: amitriptyline or nortriptyline; duloxetine for patients with concurrent depressive symptoms
• Topical: lignocaine 5% patch (Versatis, PBS Authority); capsaicin patch (specialist access)
• Refractory PHN: pain specialist referral, nerve blocks, neuromodulation, mindfulness and CBT via Better Access — these prepare the nervous system’s environment to modulate the chronic pain signal

Red flags — must-not-miss presentations

Presentation	Clinical clue	Action
HSV encephalitis	Fever + altered consciousness + seizures + focal deficit (temporal lobe)	Empirical IV aciclovir 10 mg/kg 8-hourly before confirmation; Emergency department immediately
HSV keratitis	Fluorescein dendrite on corneal staining	Topical aciclovir 3% eye ointment; avoid topical steroid alone (can worsen); urgent ophthalmology
Eczema herpeticum	Sudden monomorphic vesicles in atopic dermatitis + fever	IV aciclovir; Emergency department
Neonatal HSV	Sepsis, encephalitis, or hepatitis in neonate	IV aciclovir 60 mg/kg/day in three divided doses; specialist neonatology
Ophthalmic zoster (HZO)	Hutchinson sign — vesicle on nasal tip (nasociliary nerve)	Urgent ophthalmology; oral antiviral ± IV if severe
Ramsay Hunt syndrome	Facial palsy + ear vesicles ± hearing loss	Oral antiviral + corticosteroid; urgent ENT
Disseminated zoster	More than 20 vesicles outside the primary + adjacent dermatomes	IV aciclovir + isolation; HIV and immunocompromise workup
Primary genital HSV near term (≥34 weeks)	New genital lesions in late pregnancy	Caesarean strongly recommended — vaginal delivery carries ~40% vertical transmission risk

B. Evidence review

Antiviral therapy for acute zoster

Multiple placebo-controlled randomised trials support antiviral therapy within 72 hours of zoster rash onset. Valaciclovir and famciclovir offer equivalent efficacy to aciclovir with significantly better bioavailability (valaciclovir is an aciclovir prodrug achieving 3–5× higher plasma levels), allowing fewer daily doses that improve adherence during a painful acute illness. The evidence base for treating beyond 72 hours in ophthalmic zoster and immunocompromised patients is supported by eTG and ASHM guidance.

Shingrix vaccine efficacy

The ZOE-70 trial (Lal et al., NEJM 2015) randomised 13,900 adults aged 70 and over to two-dose recombinant zoster vaccine (Shingrix) versus placebo:

• Efficacy against herpes zoster: ≥97%
• Efficacy against PHN: above 91%
• Efficacy maintained across immunosenescent older adults

Shingrix is preferred over the older Zostavax (live-attenuated single-dose vaccine) because: substantially higher efficacy; non-live formulation safe in immunocompromised patients (where Zostavax is contraindicated); NIP-funded for a broader population; efficacy demonstrated in the oldest age groups where Zostavax was less effective.

Suppressive valaciclovir for HSV-2 transmission reduction

Corey et al. (NEJM 2004) randomised 1,484 HSV-2 serodiscordant couples to valaciclovir 500 mg daily versus placebo for eight months. Valaciclovir reduced HSV-2 transmission to the uninfected partner by approximately 50%. This is the evidence base for suppressive therapy in serodiscordant couples, used alongside condom use and behavioural counselling.

Type-specific HSV serology — evidence against routine use

The false-positive rate for type-specific HSV-2 IgG serology (predominantly affecting low-prevalence populations) is sufficient to cause clinically significant harm from unnecessary diagnosis and stigmatisation. ASHM and eTG recommend selective use only — not routine screening.

C. Shingrix vaccination — the Australian programme

Shingrix is a two-dose non-live recombinant vaccine (AS01B adjuvant system):

• Dose 1: at any point once eligible
• Dose 2: 2–6 months after Dose 1

NIP funding categories (since November 2023):

• All Australians aged 65 and over
• Immunocompromised adults aged 18 and over (solid organ and haematopoietic transplant recipients, those on chemotherapy or high-dose corticosteroids, HIV with AIDS-defining illness or CD4 count below 200, and other defined immunocompromising conditions — confirm current ATAGI criteria)

Timing after a shingles episode: ATAGI recommends waiting 6–12 months after acute zoster before administering Shingrix; confirm current scheduling advice with the Australian Immunisation Handbook.

Prior Zostavax recipients: Shingrix catch-up is recommended for better protection. Zostavax NIP funding ended in 2023.

Reactogenicity: Injection-site reactions, myalgia, fatigue, and headache are common — typically resolving within 2–3 days. Counsel patients that reactogenicity reflects a robust immune response. Do not prescribe antiviral prophylaxis around Shingrix administration — this is an immune response, not a zoster episode, and antivirals would not be appropriate.

Administration: can be delivered by a practice nurse using MBS items 10987/10997 within a GP vaccination consultation. The ATSI Health Assessment (item 715) and 75+ Health Assessment (item 707) provide structured opportunities to identify unvaccinated eligible patients.

D. Australian operations

MBS items

• Items 23/36/44 — GP consultations
• Item 69384 — HSV PCR (active lesion; differentiates HSV-1/HSV-2)
• Item 65070 — FBC; full pathology bundle for disseminated or severe presentations
• Items 10987/10997 — practice nurse vaccination consultation
• Items 965/967 — GP Chronic Disease Management Plan (chronic recurrent HSV with comorbidity; PHN qualifying as chronic neuropathic condition)
• Items 2700/2701 — Mental Health Care Plan (psychological burden of recurrent genital HSV, stigma, relationship impact; chronic PHN-related depression or anxiety)
• Items 705/715 — 75+ Health Assessment / ATSI Health Assessment (vaccination gap check including Shingrix eligibility)

PBS prescribing

• Aciclovir, valaciclovir, famciclovir — General Schedule for oral forms; topical aciclovir is OTC
• Gabapentin — Authority Required for neuropathic pain (PHN qualifies); RTPM/SafeScript monitored in all states; document indication
• Pregabalin — Authority Required for neuropathic pain; SafeScript monitored; renal dose adjust
• Amitriptyline, nortriptyline — General Schedule
• Topical lignocaine 5% patch (Versatis) — Authority Required for refractory PHN not controlled by systemic agents
• Shingrix — NIP-funded for eligible groups; private cost for ineligible patients
• Zostavax — no longer NIP-funded; use Shingrix

Referral pathways

Emergency department: suspected HSV encephalitis (altered consciousness, fever, focal deficit), eczema herpeticum, neonatal HSV, severe disseminated zoster, suspected zoster vasculopathy (stroke or TIA-like presentation).

Ophthalmology (same week): ophthalmic zoster (positive Hutchinson sign, any ocular symptoms), HSV keratitis.

ENT (urgent): Ramsay Hunt syndrome (facial palsy + ear vesicles ± hearing loss).

Obstetrics (urgent): primary genital HSV at 34 weeks gestation or beyond.

Infectious diseases/Sexual health: recurrent severe or antiviral-resistant HSV, complex HIV coinfection management, atypical or disseminated presentations requiring specialist workup.

Pain specialist: PHN not responding to gabapentinoids, amitriptyline, and topical agents in combination.

Documentation requirements:

• Offer HIV testing with all new HSV diagnoses — document the offer and outcome
• Partner notification counselling in genital HSV — document counselling provided and patient’s response
• Shingrix offer and vaccination status — document at every contact with eligible patients (65+ or immunocompromised 18+)
• PBS Authority for gabapentin or pregabalin — document indication (PHN) and confirm RTPM compliance
• Obstetric specialist consultation in pregnancy with genital HSV — document referral and advice given

AU patient resources

HealthDirect — Genital herpes, HealthDirect — Cold sores, HealthDirect — Shingles, Better Health Channel — Genital herpes, ASHM patient resources.

E. Special populations

Older adults (aged 65 and over): This group has the highest risk of both zoster and PHN. Immunosenescence drives both increased reactivation and more severe post-infectious pain. Shingrix vaccination is the highest-priority preventive intervention. When PHN develops, avoid higher doses of tricyclic antidepressants given anticholinergic burden and falls risk in older people — prefer gabapentinoids and topical agents as first-line, with early pain specialist involvement for refractory cases. Renal dose adjustment is particularly important for antiviral prescribing given age-related decline in eGFR.

Pregnancy: Aciclovir and valaciclovir are both Category B3 — considered acceptable in pregnancy, with aciclovir carrying the most accumulated safety data. Suppressive aciclovir 400 mg three times daily from 36 weeks is recommended in women with a history of recurrent genital herpes to reduce peripartum lesions and the likelihood of Caesarean delivery. Primary genital HSV at or after 34 weeks carries approximately 40% vertical transmission risk at vaginal delivery — Caesarean is strongly recommended and obstetric specialist involvement is essential. Active genital lesions at any stage of delivery also require Caesarean assessment. Shingrix is not licensed in pregnancy; discuss timing with an obstetric specialist if the patient was overdue for vaccination.

Immunocompromised patients: Higher risk of severe, atypical, multidermatomal, and disseminated HSV and zoster. Lower threshold for IV antiviral therapy and inpatient management. Multidermatomal or disseminated zoster is a prompt to review for underlying immunocompromise — including HIV testing, lymphoma screen, and review of current immunosuppressant medications. Shingrix is NIP-funded for immunocompromised adults aged 18 and over — a proactive prescribing opportunity at every relevant consultation. Unlike Zostavax (live-attenuated), Shingrix is safe in immunocompromised patients.

ATSI communities: Higher rates of zoster have been observed in some First Nations Australian communities, in part reflecting earlier onset of immunosenescence and higher chronic disease burden. ATSI Health Assessment (item 715) provides a structured opportunity to identify and address vaccination gaps, including Shingrix eligibility, and to review antiviral prescribing in those with recurrent HSV or recent zoster.

When to escalate

Refer immediately to the emergency department for suspected HSV encephalitis (fever with altered conscious state, seizures, or focal neurological deficit — start empirical IV aciclovir before confirmation), eczema herpeticum in a patient with atopic dermatitis, neonatal HSV, severe disseminated zoster in an immunocompromised patient, or any presentation suggestive of zoster vasculopathy (stroke or TIA).

Refer urgently (same week) to ophthalmology for ophthalmic zoster (positive Hutchinson sign, any eye symptoms) and HSV keratitis. Refer urgently to ENT for Ramsay Hunt syndrome. Refer urgently to obstetrics for primary genital HSV at term.

For PHN refractory to gabapentinoids, amitriptyline, and topical lignocaine, refer to a pain specialist for nerve blocks, neuromodulation, or intensive multimodal management.

For recurrent severe or antiviral-resistant HSV and complex HIV coinfection, refer to an infectious diseases or sexual health physician.

What to include in the referral: photos of the lesion or rash, PCR or serology results, antiviral treatment course to date, vaccination history, immunocompromise history, medication list, and pregnancy status.

What this article is and is not

This is general health information drawn from current Australian guidelines — Therapeutic Guidelines (eTG), Australian Immunisation Handbook, ASHM, and Australian Medicines Handbook (AMH) — and the ZOE-70 and Corey NEJM trials. It is not personal medical advice and does not create a doctor–patient relationship. All treatment decisions — including antiviral choices, suppressive therapy, management in pregnancy, and Shingrix administration — are made with the treating clinician based on individual circumstances.

For patient information: HealthDirect — Genital herpes, HealthDirect — Shingles, Better Health Channel — Genital herpes, ASHM.

For acute emergency: call 000 or attend your nearest emergency department.

---

Sources cited

1. Therapeutic Guidelines (eTG) — Herpes virus infections
2. Australian Immunisation Handbook — Zoster vaccination (Shingrix)
3. ASHM — Herpes simplex and herpes zoster resources
4. Australian Medicines Handbook (AMH)
5. PBS — Antiviral and neuropathic pain agent listings
6. NIP — National Immunisation Program schedule
7. MBS Online — HSV PCR item 69384
8. Lal A et al. — Adjuvanted herpes zoster subunit vaccine in older adults (NEJM 2015)
9. Corey L et al. — Once-daily valacyclovir to reduce transmission of genital herpes (NEJM 2004)
10. HealthDirect — Genital herpes
11. HealthDirect — Shingles
12. Better Health Channel — Genital herpes