›Airborne plus contact precautions if disseminated or immunocompromised
›Negative pressure room if available
›N95 for staff
Time critical consultations and escalation
›Escalation triggers
›Immediate ophthalmology if suspected herpes zoster ophthalmicus
›Eye symptoms
›Hutchinson sign
›Immediate neurology or infectious diseases if CNS involvement
›Encephalitis concern
›Myelitis concern
›Admission pathway if severe pain or inability to tolerate oral therapy
›Intractable pain
›Persistent vomiting
Early treatment priorities
›Antiviral timing
›Best benefit within 72 hours of rash onset
›Reduced new lesion formation
›Shorter duration of acute pain
›Consider beyond 72 hours if ongoing new lesions or high risk
›Immunocompromised
›Ophthalmic involvement
›Neurologic complications
›Analgesia first hour
›Multimodal pain control
›Acetaminophen
›NSAID if appropriate
›Neuropathic agent if moderate to severe pain
02History/hx50
Presenting pattern and timeline
›Symptom chronology
›Dermatomal pain or dysesthesia
›Burning
›Allodynia
›Rash onset time
›Hours since first vesicle
›New lesions ongoing
›Prodrome features
›Localized pain before rash
›1 to 5 days typical
›Pitfall mimic myocardial infarction or abdominal pathology
›Systemic symptoms
›Fever
›Malaise
Risk factors and prior immunity
›Host risk profile
›Age 50 years or older
›Higher postherpetic neuralgia risk
›Higher complication risk
›Immunocompromised state
›HIV
›Cancer chemotherapy
›Biologic therapy
›Varicella history
›Prior chickenpox
›Typical prerequisite for reactivation
›Varicella vaccine history
›Breakthrough possible
›Zoster vaccination history
›Recombinant zoster vaccine series
›Lower incidence
›Breakthrough still possible
Red flag symptoms
›Eye and face symptoms
›Periorbital rash
›V1 distribution
›Tip of nose lesion
›Vision change
›Blurred vision
›Photophobia
›Neurologic symptoms
›Headache severe
›Meningitis concern
›Encephalitis concern
›Weakness
›Segmental paresis
›Myelitis concern
›Dissemination symptoms
›Dyspnea
›Pneumonitis concern
›Chest pain
›Cardiac or pulmonary mimic and complication screen
03Physical Exam/exam44
Skin and mucosal exam
›Rash distribution
›Unilateral dermatomal vesicles on erythematous base
›Thoracic most common
›Cranial nerve dermatomes possible
›Crossing midline
›Consider disseminated
›Consider alternate diagnosis
›Lesion stage
›Macules to papules to vesicles
›New vesicles suggest active replication
›Crusted lesions suggest later stage
›Secondary bacterial infection features
›Honey crusting
›Purulence
Ocular and cranial nerve screening
›Eye assessment
›Visual acuity
›Baseline compare eyes
›Any reduction as urgent sign
›Conjunctival injection
›Keratitis risk
›Uveitis risk
›Fluorescein staining if available
›Dendritiform lesions
›Pseudodendrites
›Cranial nerve findings
›Facial nerve palsy
›Ramsay Hunt syndrome consideration
›Otalgia association
›Vesicles in ear canal
›Ramsay Hunt syndrome marker
Neurologic and systemic assessment
›Neurologic screen
›Mental status
›Encephalitis concern
›Medication adverse effect screen
›Motor strength focal
›Segmental zoster paresis
›Stroke mimic
›Vital signs
›Fever
›Dissemination risk
›Secondary infection risk
›Hemodynamic instability
›Alternate diagnosis
›Sepsis from superinfection
04Differential Diagnosis/ddx41
Vesicular and dermatomal mimics
›Key dermatologic mimics
›Herpes simplex infection
›Recurrent grouped vesicles
›Non dermatomal common
›Contact dermatitis
›Itchy
›Exposure pattern
›Bullous impetigo
›Staphylococcal
›Honey crust
›Neuropathic and pain mimics
›Acute coronary syndrome
›Chest dermatomal pain prodrome
›No rash early
›Renal colic
›Flank dermatomal pain prodrome
›No rash early
Serious alternate diagnoses
›Life threatening differentials
›Necrotizing soft tissue infection
›Pain out of proportion
›Rapid progression
›Meningitis or encephalitis non VZV
›Fever
›Altered mental status
›Immunocompromised rash differentials
›Disseminated HSV
›Widespread vesicles
›Mucosal involvement
›Drug eruption
›Morbilliform pattern
›Systemic involvement
Medical coding anchors
›ICD-10 and SNOMED CT mapping
›ICD-10 B02.9 zoster without complications
›SNOMED CT herpes zoster
›Dermatomal vesicular eruption
›ICD-10 B02.3 zoster ophthalmicus
›SNOMED CT herpes zoster ophthalmicus
›Trigeminal V1 involvement
›ICD-10 B02.2 zoster with nervous system complications
›SNOMED CT zoster meningitis
›SNOMED CT zoster encephalitis
05Laboratory Tests/lt28
Routine labs not required for uncomplicated cases
›Baseline testing strategy
›No labs for classic uncomplicated dermatomal presentation
›Clinical diagnosis typical
›Avoid low value testing
›Targeted labs for complications
›Immunocompromised
›Disseminated disease
Complication focused labs
›Infection and inflammation markers
›Complete blood count for systemic illness
›Leukocytosis as bacterial superinfection clue
›Neutropenia as immunosuppression clue
›C reactive protein if severe systemic features
›Supportive not diagnostic
›Trend for bacterial superinfection
›Organ function for antiviral safety
›Creatinine and eGFR for antiviral dosing
›Acyclovir crystalluria risk
›Dose adjustment need
›Liver enzymes if hepatitis concern
›Alternative diagnosis screen
›Medication baseline
CNS involvement labs
›Cerebrospinal fluid adjuncts
›CSF cell count and differential
›Lymphocytic pleocytosis typical
›Neutrophilic early possible
›CSF protein and glucose
›Elevated protein common
›Glucose usually normal
06Diagnostic Tests/dt50
Scoring Systems
›Symptom and pain measurement tools
›Zoster Brief Pain Inventory
›Pain severity 0 to 10
›Pain interference domains
›DN4 neuropathic pain questionnaire
›Neuropathic features screening
›Guides neuropathic analgesia choice
›Postherpetic neuralgia risk framing
›Clinical risk factors
›Older age
›Severe acute pain
›Severe rash burden
›Counseling application
›Early antiviral emphasis
›Early pain control emphasis
MRI
›Neuro complication imaging
›MRI brain with and without contrast for encephalitis concern
›Temporal lobe involvement possible
›Differential includes HSV
›MRI spine for myelitis concern
›Cord signal changes
›Evaluate compressive mimics
CT
›Limited role imaging
›CT head for acute neurologic deficit
›Exclude hemorrhage or mass
›Not sensitive for encephalitis
›CT orbit and face if orbital cellulitis concern
›Proptosis
›Pain with eye movement
Ultrasound
›Point of care applications
›Soft tissue ultrasound if abscess concern
›Fluctuance unclear
›Guided drainage planning
›Ocular ultrasound only if indicated and safe
›Vision loss workup adjunct
›Avoid pressure with globe injury concern
Virologic confirmation
›Lesion testing
›VZV PCR from lesion swab for atypical cases
›Immunocompromised
›Unclear diagnosis
›Direct fluorescent antibody testing where available
›Faster results
›Lower sensitivity than PCR
›CSF testing
›CSF VZV PCR for meningitis or encephalitis concern
›Higher specificity
›Sensitivity variable
›CSF VZV IgG intrathecal synthesis when PCR negative and suspicion high
›Supports diagnosis
›Specialist guided
07Disposition/dispo34
Discharge criteria
›Outpatient pathway
›Uncomplicated dermatomal disease
›Stable vital signs
›Tolerating oral intake
›Safe outpatient antivirals and analgesia
›Renal dosing arranged
›Pain controlled with oral regimen
›Follow up planning
›Primary care within 48 to 72 hours if high pain burden
›Analgesia adjustment
›PHN prevention counseling
›Ophthalmology same day for any ocular concern
›V1 rash
›Eye symptoms
Admission criteria
›Inpatient indications
›Disseminated zoster
›Airborne plus contact precautions
›IV antiviral therapy
›Immunocompromised with extensive rash
›Lower threshold for IV therapy
›Monitor visceral involvement
›CNS involvement
›IV acyclovir
›Neuro monitoring
›Severe uncontrolled pain
›Parenteral analgesia need
›Neuropathic agent initiation monitoring
Transfer criteria
›Higher level of care triggers
›Vision threatening ocular disease
›Corneal involvement
›Uveitis concern
›Suspected necrotizing infection or orbital cellulitis
›Surgical service availability
›Rapid progression
08Treatment/t88
Antiviral therapy
›Oral antivirals for uncomplicated disease
›Valacyclovir 1000 mg PO three times daily for 7 days
›Preferred for dosing convenience
›Renal dose adjustment required
›Famciclovir 500 mg PO three times daily for 7 days
›Alternative if valacyclovir unavailable
›Renal dose adjustment required
›Acyclovir 800 mg PO five times daily for 7 to 10 days
›Lower bioavailability
›Adherence barrier
›IV antivirals for severe disease
›Acyclovir 10 mg/kg IV every 8 hours
›Use ideal body weight if obese
›Dose adjust for renal function
›Ensure IV hydration to reduce nephrotoxicity
›Duration guidance
›Continue until clinical improvement
›Transition to oral to complete 10 to 14 days total for disseminated or CNS disease
›Evidence tags for antiviral use
›Class I recommendation for antivirals within 72 hours for immunocompetent adults
›Supported by randomized trial evidence
›Reduces acute pain duration
›ACEP Level B style evidence tag for early antiviral therapy
›Multiple RCTs and meta analyses support benefit
›Greatest effect early
Pain control and neuropathic therapy
›Baseline analgesics
›Acetaminophen 1000 mg PO every 6 hours as needed
›Maximum 3000 mg per day if older age or liver risk
›Avoid duplicate products
›Ibuprofen 400 mg PO every 6 to 8 hours as needed
›Maximum 2400 mg per day typical
›Avoid in CKD or GI bleed risk
›Neuropathic agents
›Gabapentin 300 mg PO at bedtime day 1
›Titrate to 300 mg PO twice daily day 2
›Titrate to 300 mg PO three times daily day 3
›Further titration 300 mg per dose every 1 to 3 days as tolerated
›Typical target 900 to 1800 mg per day
›Renal dose adjustment required
›Pregabalin 75 mg PO twice daily
›Titrate to 150 mg PO twice daily within 1 week as needed
›Renal dose adjustment required
›Amitriptyline 10 to 25 mg PO nightly
›Avoid in older adults when possible
›Anticholinergic adverse effects
›Opioid rescue for severe acute pain
›Short course only
›Avoid long duration use
›Reassess within 48 to 72 hours
›Oxycodone 5 mg PO every 6 hours as needed
›Avoid with significant respiratory risk
›Combine with bowel regimen if used
Topical therapy and skin care
›Local measures
›Cool wet compresses
›Itch reduction
›Lesion drying
›Calamine lotion
›Symptomatic itch relief
›Avoid near eyes
›Topical anesthetic for localized pain
›Lidocaine 5% patch
›Apply up to 12 hours on within 24 hours
›Avoid on open vesicles
Steroids and adjuncts
›Corticosteroids
›Not routine for uncomplicated zoster
›Limited evidence for long term PHN prevention
›Risk in diabetes and immunosuppression
›Consider only with specialist input for severe inflammatory complications
›Ophthalmic uveitis
›CNS vasculopathy
›Antibiotics only if bacterial superinfection
›Cephalexin 500 mg PO four times daily for 5 to 7 days
›Cellulitis pattern
›Purulence absent
›Add MRSA coverage if risk factors
›Prior MRSA
›Purulent lesions
Specific syndromes
›Herpes zoster ophthalmicus
›Immediate systemic antiviral therapy
›Start without delay for ophthalmology
›Prefer valacyclovir or famciclovir
›Topical ophthalmic therapy only under ophthalmology guidance
›Avoid topical steroids without specialist
›Avoid topical anesthetics outpatient
›Ramsay Hunt syndrome
›Systemic antiviral plus steroid early if specialist agrees
›Higher risk of persistent facial weakness
›ENT follow up
09Special Populations/sp31
Pregnancy
›Pregnancy considerations
›Maternal zoster usually limited fetal risk
›Reactivation differs from primary varicella
›Maternal comfort and complication prevention focus
›Antivirals in pregnancy
›Acyclovir and valacyclovir generally considered acceptable when indicated
›Shared decision making
›Exposure counseling
›Avoid contact with non immune pregnant individuals
›Cover lesions until crusted
Geriatric
›Older adult risks
›Higher postherpetic neuralgia incidence
›Early antiviral prioritization
›Early neuropathic analgesia consideration
›Medication safety
›Avoid high anticholinergic burden
›Renal dosing strict
›Falls and delirium risk
›Gabapentinoid start low and go slow
›Avoid benzodiazepines for itch or sleep
Pediatrics
›Pediatric presentation
›Usually milder in immunocompetent children
›Less PHN risk
›Shorter course
›Antiviral indications
›Immunocompromised child
›Ophthalmic involvement
›Severe rash or pain
›Weight based IV dosing
›Acyclovir 10 to 15 mg/kg IV every 8 hours
›Renal adjustment required
10Background/b39
Epidemiology
›Disease burden
›Reactivation of latent varicella zoster virus
›Lifetime risk increases with age
›Incidence rises after age 50
›Postherpetic neuralgia frequency
›Risk increases with age
›Severe acute pain as predictor
›Vaccination impact
›Recombinant zoster vaccine reduces incidence
›Breakthrough cases still occur
Pathophysiology
›Viral mechanism
›Latency in dorsal root ganglia or cranial nerve ganglia
›Reactivation with immune decline
›Anterograde spread along sensory nerve
›Dermatomal inflammation and nerve injury
›Neuropathic pain generation
›Allodynia and hyperalgesia
›Complication mechanisms
›Ophthalmic involvement
›Keratitis
›Uveitis
›CNS involvement
›Meningitis
›Encephalitis
›Vasculopathy stroke risk
Therapeutic Considerations
›Antiviral rationale
›Inhibits viral replication
›Reduced lesion formation
›Reduced acute pain duration
›Timing effect
›Highest benefit early
›Ongoing benefit in high risk beyond 72 hours
›Pain strategy rationale
›Mixed nociceptive and neuropathic pain components
›NSAID and acetaminophen for nociceptive
›Gabapentinoid or TCA for neuropathic
›PHN prevention focus
›Rapid control of acute neuritis
›Early follow up for titration
11Patient Discharge Instructions/pdi27
copy discharge instructions
›Discharge instructions
›Diagnosis explanation
›Shingles is reactivation of chickenpox virus in a nerve
›Usually improves over 2 to 4 weeks
›Medications
›Antiviral exactly as prescribed
›Pain regimen schedule
›Skin care
›Keep rash clean and dry
›Do not scratch vesicles
›Cover lesions until crusted
›Contagion precautions
›Avoid contact with people without chickenpox immunity
›Avoid newborns
›Avoid pregnant individuals without prior varicella or vaccination
›Avoid immunocompromised contacts
›Return to emergency care
›Eye pain or vision change
›Rash on forehead or tip of nose
›Severe headache or stiff neck
›Confusion or new weakness
›Fever or rapidly spreading redness around rash
›Widespread rash beyond one area
›Pain not controlled with prescribed plan
›Follow up
›Primary care follow up within 2 to 3 days if pain significant
›Ophthalmology same day for any eye symptoms
12References/r23
Guidelines and evidence sources
›Core references
›CDC shingles clinical overview and prevention guidance
›Infection control and vaccination counseling
›Recombinant zoster vaccine recommendations
›ACIP recommendations for recombinant zoster vaccine
›Adult vaccination indications
›Immunocompromised considerations
›IDSA guidance for management of VZV in immunocompromised hosts
›IV acyclovir indications
›Disseminated and CNS disease pathways
›American Academy of Ophthalmology guidance on herpes zoster ophthalmicus
›Urgent ophthalmology evaluation
›Ocular complication prevention
›Evidence tags for internal protocol use
›Class I recommendation tag
›Early systemic antiviral therapy for typical herpes zoster
›IV acyclovir for disseminated or CNS disease
›ACEP Level B style evidence tag
›RCT supported oral antiviral benefit within 72 hours
›Meta analysis supported acute pain reduction
›ACEP Level C style evidence tag
›Consultation triggers and disposition thresholds
›Expert consensus and specialty society guidance
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.