Approach to managing shingles (herpes zoster)

Antiviral therapy for shingles (herpes zoster) is indicated forMeyer, 2022Schmader, 2018Werner, 2017Werner, 2017:

• adults and adolescents who are immunocompetent and present within 72 hours of rash onset
• children who are immunocompetent and have severe or rapidly progressing infection, regardless of rash duration
• all patients with immune compromise (including those with HIV infection), regardless of rash duration.

Antiviral therapy for shingles reduces acute pain, duration of the rash, viral shedding and ocular complicationsMeyer, 2022Schmader, 2018Werner, 2017. Whether antiviral therapy reduces the incidence of postherpetic neuralgia is contentiousWerner, 2017.

If indicated, start antiviral therapy as early as possible.

Intravenous antiviral therapy is recommended for shingles in patients withSchmader, 2018:

• disseminated disease (affecting 3 or more dermatomes or more than 20 vesicles outside the area of the primary and adjacent dermatomes)
• invasive disease (eg encephalitis)
• herpes zoster ophthalmicus or herpes zoster oticus (Ramsay‐Hunt syndrome) in patients with immune compromise and in patients with nonresponsive or fulminant infection.

Oral antiviral therapy is appropriate for patients with shingles who do not meet the above criteria for intravenous therapy.

Manage acute pain with analgesia. In children, shingles is generally less painful and most children do not require treatment.

Pain can persist after shingles has resolved. For management strategies, see Postherpetic neuralgia.

Secondary bacterial infection of shingles skin lesions with Streptococcus pyogenes (group A streptococcus [GAS]) or Staphylococcus aureus can occur and should be treated as for cellulitis. If other organisms are identified on culture, alternative antimicrobials may be required.