Herpes Zoster ConcernAPPROACH

ALLERGY AND DERMATOLOGY · 19 SECTIONS

⚲

415 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Pruritus Without Rash Contact Dermatitis And Eczema Flare Herpes Zoster Concern Drug Eruption Concern And Severe Cutaneous Reaction Red Flags Urticaria Angioedema Concern Unexplained Bruising Or Bleeding Symptoms

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx48

Presenting features

›Zoster symptom characterization

›Unilateral dermatomal pain

›Vesicular rash

›Prodrome without rash

›Prior varicella infection

›Prior zoster episode

OPQRST

›Onset

›First pain or dysesthesia time

›Rash onset time

›Temporal relation pain to rash

›Provocation and palliation

›Triggered by light touch

›Worse with friction

›Worse with heat

›Relief with cooling

›Relief with analgesics

›Quality

›Burning pain

›Electric shock pain

›Pruritus

›Allodynia

›Region and radiation

›Dermatome distribution

›Crossing midline

›Face involvement

›Eye involvement symptoms

›Ear involvement symptoms

›Severity

›Pain score

›Sleep disruption

›Functional impairment

›Timing

›Constant pain

›Intermittent paroxysms

›New lesions in last 24 hours

›Duration since first lesion

Associated symptoms

›Systemic and focal symptoms

›Fever

›Headache

›Neck stiffness

›Altered mental status

›Focal neurologic deficits

›Vision changes

›Eye pain

›Photophobia

›Hearing loss

›Vertigo

›Facial weakness

02Alarm Features/alarm22

Immediate escalation triggers

›High risk presentations

›Suspected disseminated zoster

›Ophthalmic involvement with eye symptoms

›Ramsay Hunt syndrome features

›CNS infection concern

›Severe immunosuppression

›Pregnancy with severe disease

Vital signs and toxicity

›Concerning physiologic features

›Hypotension

›Tachycardia out of proportion

›Fever with rigors

›Hypoxia

›Persistent vomiting with dehydration

High risk exam findings

›Exam red flags

›Hutchinson sign

›Corneal opacity

›Vesicles on tip of nose

›Otic vesicles

›Facial nerve palsy

›Multidermatomal eruption

›Necrotic or hemorrhagic lesions

›Extensive bacterial superinfection

03Medications/meds18

Current and recent exposures

›Medication review

›Immunosuppressants

›Systemic corticosteroids

›Biologic agents

›Chemotherapy

›Antiretrovirals

›Recent antibiotics

Analgesic and neuropathic agents

›Current symptom treatments

›Acetaminophen use

›NSAID use

›Opioid exposure

›Gabapentin or pregabalin

›TCA use

›Topical lidocaine

Contraindications and interactions

›Key medication safety checks

›Renal impairment affecting antiviral dosing

›QT prolonging agents if adding TCA

›Sedating polypharmacy with gabapentinoids or opioids

04Diet/diet9

Hydration and intake

›Current intake status

›Poor oral intake

›Vomiting

›Reduced fluids

›Dark urine

Potential modifiers

›Exposures that worsen symptoms

›Alcohol use pattern

›High caffeine intake

›Sleep deprivation

05Review of Systems/ros21

Skin and lymphatic

›Skin findings

›New rash elsewhere

›Diffuse pruritus

›Purulent drainage

›Rapidly spreading erythema

Eye and ENT

›Eye and ear symptoms

›Eye pain

›Blurred vision

›Photophobia

›Hearing loss

›Tinnitus

›Vertigo

Neuro and systemic

›Neuro systemic symptoms

›Severe headache

›Neck stiffness

›Weakness

›Numbness

›Confusion

›Fever

›Dyspnea

›Chest pain

06Collateral History and Family History/chafh7

Collateral and reliability

›Context and supports

›Living situation

›Ability to isolate from high risk contacts

›Caregiver support for eye drops and meds

Family history and host factors

›Familial risk context

›Primary immunodeficiency history

›Early onset malignancy history

07Risk Factors/rf16

Immunocompromise and host risk

›Conditions increasing risk and severity

›HIV infection

›Hematologic malignancy

›Solid organ transplant

›Stem cell transplant

›Chronic kidney disease

›Diabetes mellitus type 2 (E11.9)

Exposure and transmission context

›Contact risk considerations

›Household pregnant contacts

›Household immunocompromised contacts

›Household unvaccinated contacts

Special populations

›Higher stakes groups

›Pregnancy

›Neonate exposure risk

›Severe atopic dermatitis

›Recent live vaccine contraindication context

08Differential Diagnosis/ddx38

Life threatening

›Cannot miss diagnoses

›Herpes zoster ophthalmicus with keratitis (B02.3)

›Eye pain

›Vision change

›Hutchinson sign

›VZV encephalitis or meningitis (B02.0)

›Altered mental status

›Seizure

›Meningismus

›Disseminated zoster with pneumonitis (B02.2)

›Dyspnea

›Hypoxia

›Diffuse rash

›Necrotizing soft tissue infection (M72.6)

›Pain out of proportion

›Rapid progression

Common

›Frequent alternatives

›HSV infection (B00.9)

›Recurrent grouped vesicles

›Oral or genital predominance

›Contact dermatitis (L23.9)

›Pruritic distribution

›Exposure pattern

›Cellulitis (L03.90)

›Diffuse erythema

›Warmth

›Impetigo (L01.00)

›Honey crust lesions

Less common and mimics

›Mimics and pitfalls

›Scabies (B86)

›Burrows

›Web space involvement

›Dermatomal pain without rash

›Radiculopathy

›Musculoskeletal strain

›Pityriasis rosea (L42)

›Herald patch

›Christmas tree pattern

09Past Medical History/pmh10

Relevant conditions

›Host and prior events

›Prior zoster

›Varicella vaccination history

›Immunosuppressive conditions

›Chronic kidney disease (N18.9)

›Chronic liver disease (K76.9)

Procedures and devices

›Recent healthcare exposures

›Recent chemotherapy

›Recent transplant

›Implanted devices with infection concern context

10Physical Exam/exam25

General and vitals

›Global assessment

›Toxic appearance

›Hemodynamic stability

›Fever pattern

Skin exam

›Rash characterization

›Dermatomal distribution

›Vesicles on erythematous base

›Crusting stage

›Crossing midline

›Multidermatomal involvement

›Diffuse non dermatomal lesions

›Superinfection signs

Eye and ENT exam

›Face and sensory nerve distributions

›V1 involvement distribution

›Tip of nose lesions

›Conjunctival injection

›Corneal pain

›Vesicles in ear canal

›Facial weakness

Neuro exam

›Neurologic screen

›Mental status

›Cranial nerves

›Meningismus

›Motor deficits

›Sensory deficits

11Lab Studies/labs13

When diagnosis uncertain or severe disease

›Targeted labs

›CBC with differential

›CMP with creatinine for antiviral dosing

›Glucose

›HIV testing when appropriate and consented

CNS complication workup

›If meningitis or encephalitis concern

›Blood cultures if febrile and toxic

›Lumbar puncture with CSF profile

›CSF VZV PCR if available

Test limitations

›Practical pitfalls

›Zoster can be clinical without labs

›PCR yield decreases as lesions crust

›Early neurologic disease can have subtle labs

12Imaging/img25

Scoring Systems

›Decision support for complications

›No validated single score for zoster severity in ED

›Use syndromic risk stratification based on

›Ophthalmic involvement

›Dissemination

›Immunocompromise

›CNS signs

MRI

›Neuro imaging indications

›MRI brain with and without contrast for suspected encephalitis

›MRI spine for suspected myelitis or radiculomyelitis

›Contraindications

›Non MRI compatible implants

›Severe renal dysfunction and gadolinium risk local protocol dependent

›Acute neuro screening

›CT head for altered mental status with concern for alternate intracranial process

›CT head before lumbar puncture when indicated by local protocol

›Contrast precautions

›Acute kidney injury risk assessment

›Prior anaphylactoid contrast reaction

Ultrasound

›Limited role

›POCUS soft tissue for abscess if secondary infection suspected

›Ocular ultrasound avoided if globe injury concern

›Interpretation pitfalls

›Cellulitis vs abscess overlap

›Normal scan does not exclude zoster complications

13Special Tests/spec10

Virologic confirmation

›Lesion based testing

›VZV PCR from vesicle base

›Direct fluorescent antibody testing where available

›Tzanck smear limitations

›Cannot distinguish HSV vs VZV

›Lower sensitivity than PCR

Eye and ENT focused testing

›Specialty evaluation triggers

›Slit lamp exam with fluorescein for suspected keratitis

›Intraocular pressure measurement when indicated

›Audiology or ENT evaluation for Ramsay Hunt concern

14ECG/ecg9

When to obtain

›Indications

›Chest pain with zoster vs ACS mimic

›Syncope

›Palpitations

High risk patterns

›ECG red flags

›ST elevation

›Dynamic ischemic changes

›High grade AV block

›Ventricular arrhythmia

15Assessment/ax17

Working diagnosis

›Primary considerations

›Herpes zoster without complication (B02.9)

›Herpes zoster with other nervous system involvement (B02.0)

›Herpes zoster ophthalmicus (B02.3)

›Ramsay Hunt syndrome (B02.21)

Severity stratification

›Higher risk features

›Ophthalmic distribution

›Otic distribution with facial palsy

›Immunocompromised host

›Multidermatomal disease

›Disseminated rash

›Severe pain limiting function

Key supporting features

›Clinical support

›Dermatomal vesicular eruption

›Neuropathic pain pattern

›Allodynia

›New lesions continuing

16Plan/plan59

First 5 minutes and safety checks

›Immediate priorities

›Airway and breathing support if altered or hypoxic

›IV access if toxic or poor intake

›Isolation precautions for disseminated rash or immunocompromised local protocol dependent

›Urgent ophthalmology notification for eye symptoms or V1 with Hutchinson sign

Antiviral therapy

›Antivirals

›Best benefit if started within 72 hours of rash onset

›Treat beyond 72 hours if

›New lesions continue

›Ophthalmic involvement

›Otic involvement

›Immunocompromised host

›Valacyclovir PO

›1000 mg three times daily for 7 days

›Renal dose adjustment required

›Famciclovir PO

›500 mg three times daily for 7 days

›Renal dose adjustment required

›Acyclovir PO

›800 mg five times daily for 7 to 10 days

›Renal dose adjustment required

›Acyclovir IV

›10 mg per kg every 8 hours for severe disease

›Indications

›Disseminated zoster

›CNS involvement

›Severe immunosuppression

›Hydration to reduce nephrotoxicity

›Monitor for neurotoxicity with renal impairment

Pain control and symptom management

›Analgesia ladder

›Acetaminophen

›NSAID if no contraindication

›Short course opioid if severe pain and safe follow up

›Topical lidocaine patch for focal pain

›Gabapentin

›Start low and titrate as tolerated

›Sedation precautions

›Pregabalin

›Start low and titrate as tolerated

›Sedation precautions

›Adjuncts

›Anti pruritic measures

›Sleep support avoiding sedating polypharmacy

Complication specific management

›Ophthalmic involvement

›Ophthalmology same day evaluation if eye symptoms

›Avoid topical ocular steroids unless directed by ophthalmology

›Lubricating drops for comfort

›Ramsay Hunt concern

›Early antivirals

›ENT or neurology input for facial palsy

›Eye protection if incomplete eyelid closure

›Suspected bacterial superinfection

›Culture if purulent

›Antibiotics per cellulitis pathway local protocol dependent

Reassessment loop

›Time based reassessment

›Repeat vitals within 60 to 120 minutes if pain or toxicity

›Recheck rash extent and new lesions

›Recheck neuro status if any headache or confusion

›Escalate disposition for worsening pain or spreading rash

17Disposition/dispo24

Admission and higher level care

›Admit criteria

›Disseminated zoster

›Immunocompromised with extensive disease

›CNS involvement concern

›Inability to tolerate oral antivirals

›Uncontrolled pain despite ED therapy

›Severe dehydration

›ICU criteria

›Hemodynamic instability

›Respiratory failure

›Seizure or refractory altered mental status

Observation pathway

›Observation considerations

›Moderate pain requiring parenteral analgesia

›Need for specialty evaluation same day

›Social concerns limiting adherence

Discharge criteria and follow up

›Safe discharge features

›Localized dermatomal disease

›No eye symptoms and no V1 involvement

›No neuro symptoms

›Reliable follow up and medication access

›Follow up timing

›Primary care within 48 to 72 hours for symptom check

›Ophthalmology within 24 hours for any V1 involvement

›Return visit if new neuro or eye symptoms

18Discharge Instructions/di29

Copy discharge instructions

›Diagnosis

›You have shingles caused by the varicella zoster virus

›The rash usually stays on one side of the body in a band like pattern

›Medications

›Take your antiviral exactly as prescribed until finished

›Use pain medicine as directed

›Do not take more than the recommended daily dose of acetaminophen

›Avoid mixing sedating medicines unless instructed

›Skin care and infection control

›Keep the rash clean and dry

›Do not scratch or pop blisters

›Cover the rash when around others

›Wash hands often

›Avoid contact with pregnant people and people with weak immune systems until all lesions are crusted

›Activity

›Rest as needed

›Avoid friction on the rash

›Follow up

›See your clinician in 2 to 3 days

›Same day eye doctor visit if rash is on the forehead or nose or if you have any eye symptoms

›Return to ED now if

›Eye pain

›Vision changes

›Severe headache

›Neck stiffness

›Confusion

›Weakness

›Fever with worsening rash

›Rash spreading to many areas

19References/r15

Guidelines and key sources

›CDC shingles clinical overview 2024

›Clinical features and transmission

›Antiviral treatment principles

›ACIP recombinant zoster vaccine recommendations 2022

›Indications for immunocompromised adults

›Contraindications and precautions

›American Academy of Ophthalmology herpes zoster ophthalmicus guidance 2023

›Urgent referral triggers

›Ocular complication management principles

›IDSA clinical practice guidance for management of VZV in immunocompromised hosts 2019

›IV acyclovir indications

›Duration and monitoring considerations

›Cochrane review antivirals for acute herpes zoster 2014

›Effect on acute pain

›Effect on postherpetic neuralgia

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Herpes Zoster ConcernAPPROACH

ALLERGY AND DERMATOLOGY · 19 SECTIONS

⚲

415 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx48

Presenting features

›Zoster symptom characterization

›Unilateral dermatomal pain

›Vesicular rash

›Prodrome without rash

›Prior varicella infection

›Prior zoster episode

OPQRST

›Onset

›First pain or dysesthesia time

›Rash onset time

›Temporal relation pain to rash

›Provocation and palliation

›Triggered by light touch

›Worse with friction

›Worse with heat

›Relief with cooling

›Relief with analgesics

›Quality

›Burning pain

›Electric shock pain

›Pruritus

›Allodynia

›Region and radiation

›Dermatome distribution

›Crossing midline

›Face involvement

›Eye involvement symptoms

›Ear involvement symptoms

›Severity

›Pain score

›Sleep disruption

›Functional impairment

›Timing

›Constant pain

›Intermittent paroxysms

›New lesions in last 24 hours

›Duration since first lesion

Associated symptoms

›Systemic and focal symptoms

›Fever

›Headache

›Neck stiffness

›Altered mental status

›Focal neurologic deficits

›Vision changes

›Eye pain

›Photophobia

›Hearing loss

›Vertigo

›Facial weakness

02Alarm Features/alarm22

Immediate escalation triggers

›High risk presentations

›Suspected disseminated zoster

›Ophthalmic involvement with eye symptoms

›Ramsay Hunt syndrome features

›CNS infection concern

›Severe immunosuppression

›Pregnancy with severe disease

Vital signs and toxicity

›Concerning physiologic features

›Hypotension

›Tachycardia out of proportion

›Fever with rigors

›Hypoxia

›Persistent vomiting with dehydration

High risk exam findings

›Exam red flags

›Hutchinson sign

›Corneal opacity

›Vesicles on tip of nose

›Otic vesicles

›Facial nerve palsy

›Multidermatomal eruption

›Necrotic or hemorrhagic lesions

›Extensive bacterial superinfection

03Medications/meds18

Current and recent exposures

›Medication review

›Immunosuppressants

›Systemic corticosteroids

›Biologic agents

›Chemotherapy

›Antiretrovirals

›Recent antibiotics

Analgesic and neuropathic agents

›Current symptom treatments

›Acetaminophen use

›NSAID use

›Opioid exposure

›Gabapentin or pregabalin

›TCA use

›Topical lidocaine

Contraindications and interactions

›Key medication safety checks

›Renal impairment affecting antiviral dosing

›QT prolonging agents if adding TCA

›Sedating polypharmacy with gabapentinoids or opioids

04Diet/diet9

Hydration and intake

›Current intake status

›Poor oral intake

›Vomiting

›Reduced fluids

›Dark urine

Potential modifiers

›Exposures that worsen symptoms

›Alcohol use pattern

›High caffeine intake

›Sleep deprivation

05Review of Systems/ros21

Skin and lymphatic

›Skin findings

›New rash elsewhere

›Diffuse pruritus

›Purulent drainage

›Rapidly spreading erythema

Eye and ENT

›Eye and ear symptoms

›Eye pain

›Blurred vision

›Photophobia

›Hearing loss

›Tinnitus

›Vertigo

Neuro and systemic

›Neuro systemic symptoms

›Severe headache

›Neck stiffness

›Weakness

›Numbness

›Confusion

›Fever

›Dyspnea

›Chest pain

06Collateral History and Family History/chafh7

Collateral and reliability

›Context and supports

›Living situation

›Ability to isolate from high risk contacts

›Caregiver support for eye drops and meds

Family history and host factors

›Familial risk context

›Primary immunodeficiency history

›Early onset malignancy history

07Risk Factors/rf16

Immunocompromise and host risk

›Conditions increasing risk and severity

›HIV infection

›Hematologic malignancy

›Solid organ transplant

›Stem cell transplant

›Chronic kidney disease

›Diabetes mellitus type 2 (E11.9)

Exposure and transmission context

›Contact risk considerations

›Household pregnant contacts

›Household immunocompromised contacts

›Household unvaccinated contacts

Special populations

›Higher stakes groups

›Pregnancy

›Neonate exposure risk

›Severe atopic dermatitis

›Recent live vaccine contraindication context

08Differential Diagnosis/ddx38

Life threatening

›Cannot miss diagnoses

›Herpes zoster ophthalmicus with keratitis (B02.3)

›Eye pain

›Vision change

›Hutchinson sign

›VZV encephalitis or meningitis (B02.0)

›Altered mental status

›Seizure

›Meningismus

›Disseminated zoster with pneumonitis (B02.2)

›Dyspnea

›Hypoxia

›Diffuse rash

›Necrotizing soft tissue infection (M72.6)

›Pain out of proportion

›Rapid progression

Common

›Frequent alternatives

›HSV infection (B00.9)

›Recurrent grouped vesicles

›Oral or genital predominance

›Contact dermatitis (L23.9)

›Pruritic distribution

›Exposure pattern

›Cellulitis (L03.90)

›Diffuse erythema

›Warmth

›Impetigo (L01.00)

›Honey crust lesions

Less common and mimics

›Mimics and pitfalls

›Scabies (B86)

›Burrows

›Web space involvement

›Dermatomal pain without rash

›Radiculopathy

›Musculoskeletal strain

›Pityriasis rosea (L42)

›Herald patch

›Christmas tree pattern

09Past Medical History/pmh10

Relevant conditions

›Host and prior events

›Prior zoster

›Varicella vaccination history

›Immunosuppressive conditions

›Chronic kidney disease (N18.9)

›Chronic liver disease (K76.9)

Procedures and devices

›Recent healthcare exposures

›Recent chemotherapy

›Recent transplant

›Implanted devices with infection concern context

10Physical Exam/exam25

General and vitals

›Global assessment

›Toxic appearance

›Hemodynamic stability

›Fever pattern

Skin exam

›Rash characterization

›Dermatomal distribution

›Vesicles on erythematous base

›Crusting stage

›Crossing midline

›Multidermatomal involvement

›Diffuse non dermatomal lesions

›Superinfection signs

Eye and ENT exam

›Face and sensory nerve distributions

›V1 involvement distribution

›Tip of nose lesions

›Conjunctival injection

›Corneal pain

›Vesicles in ear canal

›Facial weakness

Neuro exam

›Neurologic screen

›Mental status

›Cranial nerves

›Meningismus

›Motor deficits

›Sensory deficits

11Lab Studies/labs13

When diagnosis uncertain or severe disease

›Targeted labs

›CBC with differential

›CMP with creatinine for antiviral dosing

›Glucose

›HIV testing when appropriate and consented

CNS complication workup

›If meningitis or encephalitis concern

›Blood cultures if febrile and toxic

›Lumbar puncture with CSF profile

›CSF VZV PCR if available

Test limitations

›Practical pitfalls

›Zoster can be clinical without labs

›PCR yield decreases as lesions crust

›Early neurologic disease can have subtle labs

12Imaging/img25

Scoring Systems

›Decision support for complications

›No validated single score for zoster severity in ED

›Use syndromic risk stratification based on

›Ophthalmic involvement

›Dissemination

›Immunocompromise

›CNS signs

MRI

›Neuro imaging indications

›MRI brain with and without contrast for suspected encephalitis

›MRI spine for suspected myelitis or radiculomyelitis

›Contraindications

›Non MRI compatible implants

›Severe renal dysfunction and gadolinium risk local protocol dependent

›Acute neuro screening

›CT head for altered mental status with concern for alternate intracranial process

›CT head before lumbar puncture when indicated by local protocol

›Contrast precautions

›Acute kidney injury risk assessment

›Prior anaphylactoid contrast reaction

Ultrasound

›Limited role

›POCUS soft tissue for abscess if secondary infection suspected

›Ocular ultrasound avoided if globe injury concern

›Interpretation pitfalls

›Cellulitis vs abscess overlap

›Normal scan does not exclude zoster complications

13Special Tests/spec10

Virologic confirmation

›Lesion based testing

›VZV PCR from vesicle base

›Direct fluorescent antibody testing where available

›Tzanck smear limitations

›Cannot distinguish HSV vs VZV

›Lower sensitivity than PCR

Eye and ENT focused testing

›Specialty evaluation triggers

›Slit lamp exam with fluorescein for suspected keratitis

›Intraocular pressure measurement when indicated

›Audiology or ENT evaluation for Ramsay Hunt concern

14ECG/ecg9

When to obtain

›Indications

›Chest pain with zoster vs ACS mimic

›Syncope

›Palpitations

High risk patterns

›ECG red flags

›ST elevation

›Dynamic ischemic changes

›High grade AV block

›Ventricular arrhythmia

15Assessment/ax17

Working diagnosis

›Primary considerations

›Herpes zoster without complication (B02.9)

›Herpes zoster with other nervous system involvement (B02.0)

›Herpes zoster ophthalmicus (B02.3)

›Ramsay Hunt syndrome (B02.21)

Severity stratification

›Higher risk features

›Ophthalmic distribution

›Otic distribution with facial palsy

›Immunocompromised host

›Multidermatomal disease

›Disseminated rash

›Severe pain limiting function

Key supporting features

›Clinical support

›Dermatomal vesicular eruption

›Neuropathic pain pattern

›Allodynia

›New lesions continuing

16Plan/plan59

First 5 minutes and safety checks

›Immediate priorities

›Airway and breathing support if altered or hypoxic

›IV access if toxic or poor intake

›Isolation precautions for disseminated rash or immunocompromised local protocol dependent

›Urgent ophthalmology notification for eye symptoms or V1 with Hutchinson sign

Antiviral therapy

›Antivirals

›Best benefit if started within 72 hours of rash onset

›Treat beyond 72 hours if

›New lesions continue

›Ophthalmic involvement

›Otic involvement

›Immunocompromised host

›Valacyclovir PO

›1000 mg three times daily for 7 days

›Renal dose adjustment required

›Famciclovir PO

›500 mg three times daily for 7 days

›Renal dose adjustment required

›Acyclovir PO

›800 mg five times daily for 7 to 10 days

›Renal dose adjustment required

›Acyclovir IV

›10 mg per kg every 8 hours for severe disease

›Indications

›Disseminated zoster

›CNS involvement

›Severe immunosuppression

›Hydration to reduce nephrotoxicity

›Monitor for neurotoxicity with renal impairment

Pain control and symptom management

›Analgesia ladder

›Acetaminophen

›NSAID if no contraindication

›Short course opioid if severe pain and safe follow up

›Topical lidocaine patch for focal pain

›Gabapentin

›Start low and titrate as tolerated

›Sedation precautions

›Pregabalin

›Start low and titrate as tolerated

›Sedation precautions

›Adjuncts

›Anti pruritic measures

›Sleep support avoiding sedating polypharmacy

Complication specific management

›Ophthalmic involvement

›Ophthalmology same day evaluation if eye symptoms

›Avoid topical ocular steroids unless directed by ophthalmology

›Lubricating drops for comfort

›Ramsay Hunt concern

›Early antivirals

›ENT or neurology input for facial palsy

›Eye protection if incomplete eyelid closure

›Suspected bacterial superinfection

›Culture if purulent

›Antibiotics per cellulitis pathway local protocol dependent

Reassessment loop

›Time based reassessment

›Repeat vitals within 60 to 120 minutes if pain or toxicity

›Recheck rash extent and new lesions

›Recheck neuro status if any headache or confusion

›Escalate disposition for worsening pain or spreading rash

17Disposition/dispo24

Admission and higher level care

›Admit criteria

›Disseminated zoster

›Immunocompromised with extensive disease

›CNS involvement concern

›Inability to tolerate oral antivirals

›Uncontrolled pain despite ED therapy

›Severe dehydration

›ICU criteria

›Hemodynamic instability

›Respiratory failure

›Seizure or refractory altered mental status

Observation pathway

›Observation considerations

›Moderate pain requiring parenteral analgesia

›Need for specialty evaluation same day

›Social concerns limiting adherence

Discharge criteria and follow up

›Safe discharge features

›Localized dermatomal disease

›No eye symptoms and no V1 involvement

›No neuro symptoms

›Reliable follow up and medication access

›Follow up timing

›Primary care within 48 to 72 hours for symptom check

›Ophthalmology within 24 hours for any V1 involvement

›Return visit if new neuro or eye symptoms

18Discharge Instructions/di29

Copy discharge instructions

›Diagnosis

›You have shingles caused by the varicella zoster virus

›The rash usually stays on one side of the body in a band like pattern

›Medications

›Take your antiviral exactly as prescribed until finished

›Use pain medicine as directed

›Do not take more than the recommended daily dose of acetaminophen

›Avoid mixing sedating medicines unless instructed

›Skin care and infection control

›Keep the rash clean and dry

›Do not scratch or pop blisters

›Cover the rash when around others

›Wash hands often

›Avoid contact with pregnant people and people with weak immune systems until all lesions are crusted

›Activity

›Rest as needed

›Avoid friction on the rash

›Follow up

›See your clinician in 2 to 3 days

›Same day eye doctor visit if rash is on the forehead or nose or if you have any eye symptoms

›Return to ED now if

›Eye pain

›Vision changes

›Severe headache

›Neck stiffness

›Confusion

›Weakness

›Fever with worsening rash

›Rash spreading to many areas

19References/r15

Guidelines and key sources

›CDC shingles clinical overview 2024

›Clinical features and transmission

›Antiviral treatment principles

›ACIP recombinant zoster vaccine recommendations 2022

›Indications for immunocompromised adults

›Contraindications and precautions

›American Academy of Ophthalmology herpes zoster ophthalmicus guidance 2023

›Urgent referral triggers

›Ocular complication management principles

›IDSA clinical practice guidance for management of VZV in immunocompromised hosts 2019

›IV acyclovir indications

›Duration and monitoring considerations

›Cochrane review antivirals for acute herpes zoster 2014

›Effect on acute pain

›Effect on postherpetic neuralgia

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.