Shingles (Herpes Zoster) 🦠
Inpatient guide to recognising and managing shingles (herpes zoster): red flags, antiviral therapy, pain control, infection precautions, and when to escalate — aligned to HSE Irish guidance.
📖 Definition & Presentation
- Reactivation of latent varicella zoster virus (VZV) in a sensory dermatome after prior chickenpox
- Prodrome (48–72 h before rash): dermatomal pain, burning, itching, paraesthesia, malaise, headache
- Rash: unilateral grouped vesicles on an erythematous base in 1–2 adjacent dermatomes, stopping at the midline
- Thoracic and lumbar dermatomes most common; vesicles crust over in 7–10 days; healing may take up to 4 weeks
- Bilateral or multi-dermatomal rash — think immunocompromise or disseminated zoster
🚨 Red Flags — Escalate Urgently
- Systemically very unwell, sepsis, or suspected meningitis (neck stiffness, photophobia, mottled skin)
- Encephalitis: confusion, disorientation, behavioural change
- Myelitis: limb weakness, bladder or bowel dysfunction
- Cranial nerve palsy: double vision, ptosis, dilated pupil — CNS involvement; ED physician review
- Facial weakness — consider stroke vs Ramsay Hunt syndrome; do not attribute to zoster without careful assessment
- HZ ophthalmicus: Hutchinson sign (tip/side of nose vesicles), red eye, visual symptoms — same-day ophthalmology
- Ramsay Hunt: facial palsy ± ear pain, vesicles in ear canal, hearing loss, vertigo
- Disseminated zoster, widespread rash, or moderate–severe immunocompromise — discuss IV antivirals with ID/microbiology
- Rash >7 days since vesicle onset — oral antivirals less beneficial; focus on complications and pain
🔍 Assessment
- Map dermatome(s); note midline crossing and number of dermatomes involved
- Full skin exam including oral, genital, and perineal areas if symptomatic
- Cranial nerve exam if head/neck involvement; formal eye exam if ophthalmic distribution suspected
- Vitals, hydration status, and assessment for secondary bacterial superinfection
- Risk factors: age >50, immunosuppression, haematological malignancy, chemotherapy, biologics, steroids, HIV
- Document day of rash onset — antiviral benefit greatest within 72 hours per HSE protocol
💊 Antiviral Therapy
- Start oral antivirals as early as possible if within 72 h of rash onset (up to 7 days in selected cases per HSE)
- First-line (adults, HSE protocol): Valaciclovir 1 g PO TDS for 7 days
- Alternatives: Aciclovir 800 mg PO five times daily (approx. 4-hourly while awake) for 7 days; Famciclovir 500 mg PO TDS for 7 days
- Immunocompromised: continue oral antivirals for 2 days after crusting of lesions; seek senior/ID advice early
- Severe disease or unable to take oral therapy: IV aciclovir 10 mg/kg Q8h (use ideal body weight; reduce dose in renal impairment) — confirm local protocol
- Adjust all doses for renal impairment — check IMF/BNF renal tables or local pharmacy guidance
- Antivirals reduce acute pain duration and viral shedding; they do not eliminate post-herpetic neuralgia risk entirely
🩹 Pain & Supportive Care
- Warn patients early about zoster-associated pain (ZAP) and risk of post-herpetic neuralgia, especially age >50
- Paracetamol ± ibuprofen if no contraindications for mild–moderate nociceptive pain
- Neuropathic pain or inadequate analgesia: consider amitriptyline 10 mg nocte (titrate) or pregabalin — discuss with senior if unsure
- Avoid routine opioids where possible; escalate persistent severe pain to senior/pain team
- Keep rash clean and dry; loose clothing; do not use antibiotic creams on vesicles
- Secondary bacterial infection: treat per local cellulitis guidance if spreading erythema, purulence, or systemic upset
🛡️ Infection Control
- Shingles is less contagious than chickenpox but VZV can transmit to non-immune contacts via direct contact with vesicle fluid
- Isolate/contact precautions until all lesions are dry and crusted
- Avoid contact with: pregnant women without varicella immunity, neonates <1 month (unless mother is the case), immunocompromised individuals
- Staff with no history of chickenpox or vaccination — occupational health advice if exposed
🏥 Inpatient-Specific Considerations
- New rash in hospital — consider whether patient was incubating on admission vs nosocomial exposure
- Review immunosuppressive therapy with treating team; do not stop steroids or chemotherapy without specialist input
- Oncology/haematology inpatients: low threshold for IV aciclovir and ID/microbiology review
- Document rash onset date, antiviral start time, and ophthalmology/neurology referrals made
- On discharge: GP follow-up, pain plan, safety-netting for worsening eye symptoms or neurology
- Shingles vaccine is available privately in Ireland (not on medical card); discuss with GP for future prevention — NIAC Chapter 23
📞 When to Consult
| Situation | Consult |
|---|---|
| Hutchinson sign, red eye, visual symptoms | Ophthalmology / regional eye unit — same day |
| Facial palsy with ear symptoms | ENT ± neurology — Ramsay Hunt |
| Immunocompromised or disseminated disease | Microbiology / ID / oncology |
| Diagnostic uncertainty or atypical rash | Dermatology |
| Severe or refractory neuropathic pain | Pain team / palliative care |
| Recurrent zoster within 6 months | Immunology / HIV screen — discuss with senior |
🔗 Related Topics
Based on
Note Template
Ready-to-use clinical note structure
🕒 08 / 07 / 2026 — 23:32 ATRP re: shingles (herpes zoster) Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [immunosuppression, malignancy, diabetes] 🧾 Hx: • Rash onset: [date/time] — day [__] since vesicles • Prodrome: dermatomal pain / burning / paraesthesia • Dermatome(s): [thoracic / lumbar / trigeminal / other] • Eye symptoms: [none / red eye / visual change] • Ear / facial symptoms: [none / ear pain / facial weakness] 🩺 Exam: • Vitals: HR __ BP __ Temp __ • Rash: unilateral vesicles in [dermatome], crusting [yes/no] • Hutchinson sign: [yes/no] • Cranial nerves / eye exam: [normal / findings] • Secondary infection: [yes/no] 📋 Impression: Herpes zoster — [uncomplicated / ophthalmicus / disseminated / immunocompromised] 📌 Plan: • Antiviral: [valaciclovir 1g TDS / aciclovir / IV aciclovir] — started [time] • Analgesia: [paracetamol / neuropathic agent] • Infection control until lesions crusted • Referrals: [ophthalmology / ID / dermatology — or none] • Safety-netting given re eye symptoms and neurology 👤 [Your Name], [Role] IMC: _______