Herpes Zoster Infection in Adults
|Publication: 20/10/2008 --|
|Last review: 09/08/2021|
|Next review: 09/08/2024|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2021|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
GUIDELINE FOR THE MANAGEMENT OF HERPES ZOSTER INFECTION (SHINGLES) IN ADULTS
- Diagnostics and investigations
- Specialist referral
- Antiviral treatment
- Non-antimicrobial treatment
- Infection prevention and control
- Herpes zoster (Shingles) is a clinical manifestation of the reactivation of latent varicella zoster virus infection.
- Diagnosis of herpes zoster is usually made by clinically assessing the patient for typical symptoms, which include:
- Rash; usually a unilateral vesicular eruption in a dermatomal distribution.
- Acute neuritis; usually in the same distribution as the rash. The pain may precede the onset of the rash, and may persist as post herpetic neuralgia.
- Diagnosis can be more difficult in certain circumstances, for example:
- Herpes simplex in the sacral or cervical areas may be difficult to distinguish clinically from herpes zoster.
- Atypical manifestations can occur in immunocompromised patients including intermittently recurrent lesions, involvement of multiple dermatomes and lesions that appear as chronic crusts or nodules. Lesions may be widespread and the patient systemically unwell (disseminated herpes zoster).
- If there is diagnostic uncertainty, a flock e-Swab for HSV, VZV and enterovirus PCR should be taken by removing the top from a lesion and swabbing the base.
Herpes zoster in the ophthalmic distribution of the trigeminal nerve should be referred to ophthalmology. Immunocompromised patients or those with complicated presentations (e.g. Ramsey Hunt syndrome) should be discussed with infectious diseases or virology.
Aciclovir PO 800mg five times daily
Use Aciclovir IV 10mg/kg3 8-hourly if neurological/ocular complications/head and neck vesicles
Aciclovir PO 800mg five times daily
Aciclovir IV 10mg/kg3 8-hourly
Valaciclovir PO 1g 8-hourly
Minimum course 10 days. Continue until 48 hours after crusting of lesions
- Consider oral switch from IV aciclovir as per above table if patient is systemically well and no new vesicles have appeared for 24 hours.
- Oral treatment with close observation may be appropriate first-line in certain immunosuppressed patients. In this situation, valaciclovir should be used. This should be discussed on a case-by-case basis with the clinical team responsible for immunosuppression (e.g. haematology, rheumatology). The decision to use oral therapy should take into account the severity of herpes zoster and the nature of immunosuppression, including expected impairment to cell-mediated immunity.
- Recurrent shingles in immunocompetent or immunocompromised patients should be discussed with an infection specialist.
- Follow the WHO analgesic ladder to treat pain in Herpes Zoster. Note that agents to treat neuropathic pain (such as gabapentin and pregabalin) may be required.
- Chlorphenamine orally can be used to relieve itch.
- Corticosteroids are not indicated routinely in uncomplicated herpes zoster. They may be indicated in patients with severe pain or involvement of cranial nerves, however this should be discussed with infectious diseases or virology.
Herpes zoster vaccine is offered routinely to all people at age 70 years with the aim of lowering the incidence and severity of herpes zoster in older people. The vaccine is live attenuated and should not be given to immunosuppressed individuals without a prior clinical risk assessment. In immunocompetent individuals who develop herpes zoster, vaccination should be delayed for one year.
- Patients with herpes zoster on exposed areas (e.g. face or eye) or those with a disseminated rash should be placed in source isolation until crusting of all lesions.
- In wards containing immunocompromised patients (e.g. haematology / oncology), all patients with herpes zoster should be placed in source isolation (negative or neutral pressure) regardless of the location of the lesions.
- Contact the IPC team for further advice.
- Longer durations may be needed for those with ocular or neurological complications.
- For immunocompetent patients, antiviral treatment should ideally be started within 72 hours of rash onset but can be considered after this if new vesicles are forming.
- Use ideal body weight to calculate dosing in obese patients. For underweight patients use actual body weight.
- All immunocompromised patients should receive antivirals.
|Target patient group:||Adults with suspected herpes zoster infection (shingles)|
|Target professional group(s):||Secondary Care Doctors
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