Eduovisual
Skin & Subcutaneous Tissue
Herpes zoster: management and vaccine prevention
— Lifetime risk ~30% in US adults; incidence rises sharply after age 50 and again after 60.
— ~1 million US cases/year. Recurrence ~5–6% over a lifetime (higher in immunocompromised).
— Age ≥50 (waning cell-mediated immunity to VZV)
— Immunosuppression: HIV, hematologic malignancy, solid organ/HSCT transplant, chronic steroids, biologics (especially JAK inhibitors, anti-TNF)
— Diabetes, COPD, CKD, depression, physical trauma to dermatome
— Female sex, family history
— Older adult with prodromal burning/itching/paresthesia in a band-like distribution 2–3 days before rash
— Unilateral grouped vesicles on erythematous base, not crossing midline, in a single dermatome (most often thoracic T3–L2, then ophthalmic V1)
— Atypical: pain without rash (zoster sine herpete), disseminated rash (>20 vesicles outside primary dermatome → suggests immunocompromise)
— Postherpetic neuralgia (PHN) is the most common and feared complication, affecting 10–18% overall and up to 30% of those >60.
— Ophthalmic zoster (HZO) threatens vision; otic involvement → Ramsay Hunt; dissemination can be life-threatening.
Board pearl: A dermatomal vesicular rash that does not cross the midline in an adult ≥50 is zoster until proven otherwise — start oral antivirals within 72 hours of rash onset even before confirmatory testing, because the time-sensitive benefit (reduced acute pain, faster healing, possibly less PHN) is greatest when initiated early. Confirmatory PCR is for atypical cases, not routine outpatient diagnosis.
— Prodrome (1–5 days, occasionally up to 7): localized burning, itching, tingling, lancinating pain, or hyperesthesia in a dermatome; may mimic MI, cholecystitis, renal colic, or radiculopathy depending on location.
— Acute eruptive phase (7–10 days): erythematous macules → papules → grouped vesicles on erythematous base → pustules.
— Crusting (2–4 weeks): lesions crust over; once all lesions crusted, patient is no longer infectious.
— Sharp, stabbing, burning, throbbing, or electric-shock; often allodynia (light touch painful).
— Severity correlates with age and predicts PHN risk.
— Onset and laterality of rash and pain
— Time since rash onset (drives antiviral decision-making)
— Prior varicella infection or varicella vaccination history
— Zoster vaccination status (Shingrix doses and dates)
— Immunosuppressive conditions/medications, HIV risk, malignancy
— Eye symptoms (pain, redness, blurred vision, photophobia), facial weakness, hearing loss, vertigo, tinnitus
— Pregnancy status (for household contacts and patient)
— Contacts with: pregnant women without varicella immunity, neonates, immunocompromised
— Zoster sine herpete: dermatomal pain without rash; diagnosed via VZV PCR of CSF or serology.
— Recurrent zoster, multidermatomal, or disseminated zoster → screen for underlying immunosuppression including HIV testing and age-appropriate malignancy workup.
— Young adult (<50) with zoster → consider HIV testing and review immunosuppressants.
Step 3 management: A 35-year-old with unprovoked zoster warrants HIV testing; a 70-year-old with classic thoracic zoster does not need malignancy workup but does need pain severity assessment and same-day antiviral initiation. Document hours since rash onset in the chart — it determines treatment urgency and shapes the counseling script.
— Unilateral, dermatomal grouped vesicles on erythematous base, sharply demarcated at midline.
— Lesions in various stages simultaneously (macule, papule, vesicle, pustule, crust) — unlike smallpox/varicella where lesions are in same stage.
— Most common dermatomes: thoracic (50%), cervical, lumbar; trigeminal V1 (10–15%) is highest-risk.
— Hutchinson's sign: vesicles on the tip, side, or root of the nose (nasociliary branch) → predicts ocular involvement (~50–85%).
— Check visual acuity, conjunctival injection, corneal fluorescein staining (pseudodendrites), anterior chamber, IOP.
— Ophthalmology referral same day for any V1 involvement.
— Vesicles in external auditory canal/auricle + peripheral CN VII palsy ± hearing loss, vertigo, tinnitus, hyperacusis, ageusia anterior 2/3 tongue.
— Worse prognosis than Bell palsy; ENT or neurology referral.
— ~3–5% develop segmental motor weakness (e.g., diaphragm with C3–5, abdominal pseudohernia with thoracic zoster).
— >20 vesicles outside primary dermatome or visceral involvement (pneumonitis, hepatitis, encephalitis) → presumed immunocompromised; needs inpatient IV acyclovir and airborne + contact precautions.
— Sensory: dermatomal hypoesthesia/hyperesthesia, allodynia
— Motor: targeted to affected myotome
— Cranial nerves if facial/cranial involvement
CCS pearl: When you see V1 zoster on a CCS case, your next two orders should be ophthalmology consult and oral valacyclovir 1 g TID (or IV acyclovir if sight-threatening/immunocompromised). Document Hutchinson's sign explicitly — it directly justifies the referral and dosing intensity.
— No labs or imaging required for typical outpatient presentations.
— Treatment should not be delayed awaiting confirmatory testing.
— Atypical rash (non-dermatomal, multidermatomal, prolonged)
— Recurrent episodes
— Immunocompromised hosts
— Suspected zoster sine herpete
— Suspected CNS involvement (encephalitis, myelitis, vasculopathy/stroke)
— Pregnant patients or neonatal exposure questions
— VZV PCR of vesicle fluid, scab, or tissue swab — highest sensitivity and specificity; distinguishes wild-type from vaccine strain.
— Unroof a fresh vesicle and swab the base; place in viral transport medium.
— Direct fluorescent antibody (DFA): rapid, sensitive but less than PCR; distinguishes HSV from VZV.
— Tzanck smear: shows multinucleated giant cells but cannot distinguish HSV from VZV — low yield, mostly historical.
— Viral culture: slow, low sensitivity; rarely used.
— Serology (IgG/IgM): not useful acutely; IgG confirms prior exposure (useful pre-vaccination only in rare scenarios — Shingrix does not require serologic screening).
— Lumbar puncture with CSF VZV PCR and intrathecal anti-VZV antibody index
— MRI brain/spine for vasculopathy, myelitis, or stroke in younger patient with zoster
— HIV test if <50 with zoster, or atypical/disseminated
— CBC, CMP if systemic symptoms; consider age-appropriate cancer screening
Key distinction: PCR > DFA > culture > Tzanck. Tzanck smear is a distractor on Step 3 — it shows the multinucleated giant cells of either HSV or VZV, so it cannot confirm zoster. If a question offers Tzanck and PCR, always pick PCR.
— Slit-lamp exam with fluorescein staining — pseudodendrites (raised, branching, no terminal bulbs, stain poorly) differ from HSV true dendrites (terminal bulbs, stain well).
— Tonometry for IOP (zoster uveitis can raise IOP)
— Dilated fundus exam if posterior involvement suspected (acute retinal necrosis)
— Visual acuity at every visit; serial follow-up
— VZV encephalitis: altered mental status, seizures; CSF lymphocytic pleocytosis, elevated protein, positive VZV PCR → IV acyclovir 10–15 mg/kg q8h.
— VZV vasculopathy: ischemic or hemorrhagic stroke weeks-months after zoster, especially HZO; MRI/MRA, CSF anti-VZV IgG with elevated index. Treat with IV acyclovir + consider steroids.
— Myelitis: spinal cord involvement → urgent MRI with contrast.
— Audiometry if hearing loss; ENT referral.
— CXR if respiratory symptoms (VZV pneumonitis)
— LFTs (VZV hepatitis)
— Blood VZV PCR can be sent in immunocompromised
— Numerical rating scale, neuropathic pain inventory; document at each visit
— Quantify allodynia, baseline function — guides escalation to neuropathic agents
— Confirm laterality, dermatome, immune status, rash onset date, antiviral start date — important for QI metrics and for delaying Shingrix until after acute episode resolves (typically wait until rash resolved, often ≥6–12 months later or per shared decision).
Board pearl: A patient with prior HZO who presents with new TIA or stroke weeks later — think VZV vasculopathy. CSF anti-VZV IgG with elevated CSF:serum antibody index is more sensitive than CSF PCR (which may be negative late). Treat with IV acyclovir × 14 days, often with adjunctive corticosteroids.
— Step 1: Is rash <72 hours old? → Antivirals strongly indicated.
— Step 2: Is rash >72 hours old but new lesions still forming, or is patient immunocompromised, or HZO/Ramsay Hunt/disseminated/motor/CNS involvement? → Antivirals still indicated.
— Step 3: Is rash >72 hours, all crusted, no complications, immunocompetent? → Antivirals offer minimal benefit; focus on pain control.
— Accelerate rash healing
— Reduce acute pain duration and severity
— Reduce viral shedding and transmission
— Reduce risk and severity of postherpetic neuralgia (PHN) (evidence modest but consistent)
— Prevent ocular, neurologic, and disseminated complications
— Outpatient: immunocompetent, localized dermatomal zoster, no ocular/CNS involvement, tolerating PO, adequate pain control.
— Inpatient (IV acyclovir): disseminated zoster, visceral involvement, severely immunocompromised (HSCT, induction chemo, untreated HIV with low CD4), sight-threatening HZO, CNS involvement, motor weakness threatening function (e.g., diaphragm).
— Mild: acetaminophen, NSAIDs
— Moderate: add gabapentin or pregabalin, TCA (nortriptyline), topical lidocaine
— Severe: short-course opioids (tramadol, oxycodone) with caution; consider nerve block in refractory cases
— Keep lesions clean and dry; cool compresses; calamine
— Cover lesions to reduce transmission
— Avoid topical antibiotics unless bacterial superinfection
Step 3 management: Steroids are NOT routinely recommended for uncomplicated zoster. Consider only in specific scenarios (Ramsay Hunt, severe HZO with ophthalmology guidance) — they do not prevent PHN and add side effects. This is a frequently tested distractor.
— Valacyclovir 1000 mg PO TID × 7 days — preferred for adherence (TID vs 5×/day)
— Famciclovir 500 mg PO TID × 7 days
— Acyclovir 800 mg PO 5×/day × 7–10 days — cheapest but inconvenient, lower bioavailability
— Maximum benefit if started within 72 hours of rash onset
— Still treat if >72 hours and new lesions forming, immunocompromised, or any complication
— 10 mg/kg IV q8h (use ideal body weight; some use 15 mg/kg for CNS/severe)
— Indications: disseminated/visceral zoster, severe HZO, CNS involvement, severely immunocompromised, inability to tolerate PO
— Transition to PO valacyclovir once stable and improving
— Acetaminophen 1 g q6h; NSAIDs if no contraindication
— Gabapentin 300 mg qHS, titrate to 300–1200 mg TID; or pregabalin 75 mg BID titrated to 150–300 mg BID
— Nortriptyline 10–25 mg qHS titrated up (caution elderly, anticholinergic load)
— Topical lidocaine 5% patch (off-label in acute, approved for PHN) — useful for allodynia
— Short-course opioids (tramadol, oxycodone) for severe pain refractory to above; document opioid stewardship
— Maintain hydration (especially IV acyclovir — crystal nephropathy)
— Report new neuro symptoms (acyclovir neurotoxicity: tremor, confusion, myoclonus — especially in renal impairment)
— Adjunctive prednisone (60 mg taper) modestly reduces acute pain and accelerates healing but does not prevent PHN. Reserve for severe acute pain in healthy adults, Ramsay Hunt, or with ophthalmology input in HZO.
Board pearl: When the stem says "patient cannot afford valacyclovir," the answer is acyclovir 800 mg 5×/day — same efficacy, lower cost, worse adherence. Always pair antiviral choice with patient-centered counseling about the 5×/day burden.
— Mechanism: nerve injury → peripheral and central sensitization
— Treat as neuropathic pain syndrome
— Gabapentin: start 300 mg qHS, titrate by 300 mg q3 days to 1800–3600 mg/day divided TID. Renally dose. SE: sedation, edema, dizziness.
— Pregabalin: 75 mg BID → 150–300 mg BID; faster onset, predictable kinetics; renally dose; Schedule V.
— Tricyclic antidepressants — nortriptyline or desipramine preferred over amitriptyline in elderly (fewer anticholinergic effects). Start 10–25 mg qHS, titrate to 75–150 mg.
· Avoid in glaucoma, urinary retention, recent MI, severe heart block, suicide risk; ECG before initiation in older adults.
— Topical lidocaine 5% patch: up to 3 patches × 12 hrs/day; excellent in localized PHN, minimal systemic absorption, first-line in elderly.
— Topical capsaicin 8% patch (clinic-applied): for refractory localized PHN.
— Duloxetine or venlafaxine (SNRIs) — useful when comorbid depression
— Tramadol (weak opioid + SNRI activity)
— Strong opioids only with specialist guidance, structured agreements
— Nerve blocks, intrathecal therapy, spinal cord stimulation in refractory cases — pain medicine referral
— Routine systemic steroids (no PHN prevention)
— Carbamazepine (less evidence in PHN than trigeminal neuralgia)
— Benzodiazepines for pain (no efficacy, fall/dependence risk)
— Start low, go slow; Beers list cautions for TCAs, gabapentinoids (falls, sedation, cognitive impairment)
— Topical lidocaine is the safest starting point in frail older adults
— Avoid combining opioids + gabapentinoids when possible (FDA warning: respiratory depression)
Key distinction: Antivirals during acute zoster reduce acute pain and may modestly reduce PHN incidence; they do NOT treat established PHN. Once pain persists ≥90 days, switch the framework to chronic neuropathic pain management, not more antiviral.
— Highest PHN risk (up to 30–50% in ≥80) and highest hospitalization rate
— Increased risk of HZO complications and disseminated disease
— Polypharmacy and drug interactions: valacyclovir generally well-tolerated; watch for renal dose adjustment
— Neurotoxicity from acyclovir/valacyclovir more common with renal impairment + advanced age: tremor, confusion, hallucinations, myoclonus — often misattributed to dementia or delirium
— Valacyclovir for zoster (normal: 1 g TID)
· CrCl 30–49: 1 g BID
· CrCl 10–29: 1 g daily
· CrCl <10 or HD: 500 mg daily (after HD on dialysis days)
— Famciclovir for zoster (normal: 500 mg TID)
· CrCl 40–59: 500 mg BID
· CrCl 20–39: 500 mg daily
· CrCl <20: 250 mg daily; HD: 250 mg after each dialysis session
— Acyclovir IV: reduce dose and/or extend interval per CrCl; ensure aggressive hydration to prevent crystal nephropathy
— No specific dose adjustments for antivirals; gabapentin/pregabalin not hepatically metabolized (renal clearance) — relatively safe
— TCAs and duloxetine require caution in hepatic dysfunction
— Recombinant zoster vaccine (Shingrix) recommended for all immunocompetent adults ≥50; efficacy >90% even in 70s and 80s
— Two doses, 2–6 months apart
— No upper age limit
— Pain medications (gabapentinoids, TCAs, opioids) increase fall risk — pair prescription with fall precautions counseling, deprescribe other sedatives if possible
Step 3 management: Elderly patient with zoster + CKD on full-dose valacyclovir presenting with new confusion and myoclonus → stop valacyclovir, hydrate, consider hemodialysis if severe. This is acyclovir neurotoxicity, not stroke or encephalitis — dose adjustment for CrCl prevents it.
— Zoster in pregnancy is uncommon and not associated with congenital varicella syndrome (unlike primary varicella).
— Acyclovir and valacyclovir are Category B (now narrative labeling) — considered safe; use valacyclovir 1 g TID × 7 days for moderate-severe zoster.
— Avoid live vaccines in pregnancy; Shingrix is non-live recombinant but deferred during pregnancy per ACIP (limited data, not contraindicated).
— Counsel about exposure precautions for non-immune pregnant contacts of the patient (zoster lesions can transmit VZV → varicella in non-immune individuals).
— Zoster in children is rare and usually mild; more common if primary varicella before age 1 or with immunosuppression.
— Antivirals generally reserved for immunocompromised children, ophthalmic involvement, or severe disease.
— Acyclovir 20 mg/kg (max 800 mg) PO 4×/day × 5 days.
— Pediatric zoster in an otherwise healthy child does not mandate immunodeficiency workup, but recurrent or disseminated cases do.
— Higher rates of disseminated zoster, visceral involvement, prolonged course, chronic verrucous lesions, acyclovir-resistant strains
— IV acyclovir for moderate-severe disease in significantly immunocompromised (HSCT, induction chemo, advanced HIV)
— Foscarnet for acyclovir-resistant VZV (suspect in immunocompromised with non-healing lesions despite therapy)
— Shingrix is recommended for immunocompromised adults ≥19 (ACIP 2021/2022 update) — HSCT, hematologic malignancy, solid organ transplant, HIV, on immunosuppressive therapy
— Any adult <50 with zoster → HIV test
— Multidermatomal or recurrent zoster suggests advanced HIV — check CD4
Board pearl: Zoster during pregnancy ≠ congenital varicella risk (the fetal risk is from maternal primary varicella in 1st/early 2nd trimester or perinatally, not from reactivation zoster). Treat the mother for symptoms; do not offer VZIG to fetus/neonate for maternal zoster alone.
— Pain ≥90 days after rash; 10–18% overall, 30%+ in ≥60, up to 50% in ≥80
— Strongest predictors: older age, severe acute pain, severe rash, prodromal pain, ophthalmic involvement
— Can persist months to years; major contributor to depression, sleep disruption, functional decline
— Keratitis, pseudodendrites, uveitis, scleritis, episcleritis
— Acute retinal necrosis (sight-threatening) — rapidly progressive, photopsia, vision loss → IV acyclovir + intravitreal foscarnet
— Chronic neurotrophic keratopathy, postherpetic ocular neuralgia, secondary glaucoma
— Ramsay Hunt syndrome (CN VII palsy + ear vesicles)
— VZV meningoencephalitis, myelitis
— VZV vasculopathy → ischemic/hemorrhagic stroke (risk elevated for ~6–12 months post-zoster, especially HZO)
— Segmental motor weakness (diaphragmatic paralysis, abdominal pseudohernia, limb weakness)
— Guillain-Barré–like syndrome (rare)
— Increased risk of MI and stroke in the weeks-months after zoster, especially with HZO — counsel patients and optimize ASCVD risk factors
— Bacterial superinfection (S. aureus, group A Strep) — cellulitis, impetiginization → topical mupirocin or oral antibiotics if extensive
— Scarring, dyspigmentation
— Pneumonitis, hepatitis, pancreatitis, encephalitis — high mortality without IV antivirals
— Depression, anxiety, sleep disorders, social isolation — especially with PHN
— Loss of independence in elderly; nursing home admission risk after severe episode
CCS pearl: Order ASCVD risk reassessment (lipid panel, BP control, statin review) for any patient after zoster, especially HZO — there is a real, time-limited increase in cardiovascular events that is testable as a longitudinal management item.
— Any V1 dermatome involvement, even before eye symptoms
— Hutchinson sign (nasal tip vesicles)
— Eye pain, redness, vision changes, photophobia
— Pseudodendrites on slit-lamp
— Ramsay Hunt syndrome — start antivirals + steroids (in consultation), audiology
— Multiple cranial nerve involvement, suspected encephalitis or myelitis
— Disseminated zoster (>20 vesicles outside primary dermatome)
— Visceral involvement (pneumonitis, hepatitis, encephalitis)
— Severely immunocompromised (HSCT, induction chemo, untreated HIV with CD4 <200, high-dose steroids/biologics)
— Sight-threatening HZO (acute retinal necrosis)
— CNS involvement (meningoencephalitis, myelitis, vasculopathy with stroke)
— Inability to tolerate PO; intractable pain
— Motor zoster threatening function (diaphragm, limb)
— Respiratory failure from VZV pneumonitis
— Hemodynamic instability, sepsis from bacterial superinfection or disseminated VZV
— Status epilepticus from VZV encephalitis
— Stroke from VZV vasculopathy requiring neurocritical care
— Localized zoster, immunocompetent: standard precautions + cover lesions
— Disseminated zoster OR any zoster in immunocompromised: airborne + contact precautions, negative-pressure room until lesions crusted
— Healthcare workers: VZV-immune staff only; non-immune staff exposed should be removed from patient care days 8–21 post-exposure (or 28 if given VZIG)
— PHN refractory to first/second-line agents
— Need for interventional procedures (nerve blocks, intrathecal therapy)
Step 3 management: A bone marrow transplant patient with new dermatomal vesicles always gets admission and IV acyclovir, regardless of how localized the rash looks — risk of dissemination and visceral spread is high and benefit of early IV therapy is large.
— Recurrent grouped vesicles on erythematous base, but typically NOT dermatomal, often orolabial or genital, recurs in same location
— HSV can occasionally present in a zosteriform/dermatomal pattern — PCR distinguishes
— Treatment: acyclovir/valacyclovir at HSV doses (lower than zoster doses)
— Generalized, centripetal, lesions in different stages but spread across multiple dermatomes
— Usually children; in adults, more severe with pneumonitis risk
— Vesicles on erythematous base ("dewdrop on a rose petal")
— HSV superinfection of atopic dermatitis
— Punched-out erosions, monomorphic vesicles, systemically ill
— Treat with IV/PO acyclovir; dermatology urgent
— PCR differentiates
— Vesicles on hands, feet, oral mucosa; not dermatomal; usually children
— Pearly umbilicated papules, not vesicles; not painful; persistent
— Lesions all in same stage, centrifugal, deep, on palms/soles, severely ill — distinct from zoster
— Lesions in same stage, lymphadenopathy, anogenital predominance, recent exposure history
— Honey-crusted bullae, S. aureus, not dermatomal, not painful in same way
Key distinction: Dermatomal + unilateral + does not cross midline = zoster. Recurrent in same location, often genital/orolabial = HSV. Generalized in different stages = primary varicella. Same stage + palms/soles + ill = smallpox/mpox concern.
— Can be linear/streaky, vesicular, intensely pruritic
— Crosses dermatomes; exposure history; itch > pain
— Erythematous, warm, tender, expanding — but lacks vesicles, not dermatomal
— May complicate zoster as superinfection
— Tense or flaccid bullae, often elderly, generalized; biopsy with DIF for diagnosis
— Thoracic dermatomal prodrome can mimic ACS, PE, cholecystitis, pancreatitis
— Right upper quadrant zoster pain misdiagnosed as biliary colic; LLQ as diverticulitis
— Renal colic, MSK pain, radiculopathy
— Always reexamine skin in a patient with unexplained unilateral pain — the rash appears 2–3 days later
— Dermatomal pain, but mechanical, no rash, neurologic findings
— Lancinating facial pain in V2/V3, trigger points, no rash
— Carbamazepine first-line
— Grouped papulovesicles, often linear, intensely pruritic; bilateral or random
— History clarifies
— Recurrent same-site lesions with drug exposure
Board pearl: A 65-year-old with 2 days of unilateral right chest wall pain, normal ECG, normal troponin, normal CXR is a classic stem for prodromal zoster — discharge home with anticipatory guidance and re-examine in 48–72 hours; the rash makes the diagnosis. Avoid premature anchoring on cardiac etiology, but document the ACS rule-out clearly.
— Adjuvanted, non-live glycoprotein E subunit
— 2-dose series, 2–6 months apart IM (deltoid)
— >90% efficacy against zoster and PHN in immunocompetent adults; durable >7–10 years
— Replaced live attenuated Zostavax (no longer available in US)
— All immunocompetent adults ≥50: 2 doses 2–6 months apart
— Immunocompromised or immunodeficient adults ≥19: 2 doses 1–6 months apart (shorter interval acceptable, e.g., 1–2 months)
— Includes: HSCT, hematologic malignancy, solid organ transplant, HIV, autoimmune disease on immunosuppressants, JAK inhibitors, biologics
— No upper age limit
— Prior zoster episode: vaccinate after acute episode resolves (no firm interval; many wait until pain controlled and rash healed; commonly 6–12 months later or sooner per shared decision)
— Prior Zostavax: revaccinate with Shingrix (≥2 months after Zostavax)
— Unknown varicella history: still vaccinate; no serologic screening needed
— Pregnancy: defer until postpartum
— Acute illness: defer until recovered
— Co-administration: can give with influenza, COVID-19, pneumococcal vaccines (separate sites)
— Severe allergic reaction to prior dose or component
— Current zoster episode (defer)
— Local: pain, redness, swelling (common, 80%+)
— Systemic: myalgia, fatigue, headache, fever (~50%) — usually 2–3 days
— Counsel patients to plan around these symptoms (avoid scheduling dose before important events); improves completion of 2nd dose
— ASCVD risk optimization (post-zoster CV event risk)
— Treat depression and sleep impairment from PHN
Step 3 management: Complete the 2-dose series even if patient had zoster between doses — do not restart. Track second-dose compliance actively; incomplete series is the #1 preventive medicine gap in zoster vaccination, and the 2nd dose drives long-term efficacy.
— Phone or in-person check at 3–7 days to assess pain control, rash progression, antiviral tolerance
— In-person visit at 2–4 weeks to confirm rash healing, screen for PHN, address mood/sleep
— HZO patients: ophthalmology follow-up at intervals determined by ophthalmologist (often weekly initially)
— Use NRS or validated neuropathic pain tools at each visit
— Track functional status: sleep, ADLs, mood
— Escalate from acetaminophen/NSAIDs → gabapentinoid/TCA/topical lidocaine → pain medicine referral if pain persists ≥3 months
— Gabapentin/pregabalin: sedation, edema, falls; renal function
— TCAs: orthostatic BP, anticholinergic side effects, baseline ECG in elderly (QT, conduction)
— Opioids: state PDMP check, structured agreement, lowest effective dose, naloxone co-prescription
— Infectivity: zoster lesions transmit VZV to non-immune contacts → varicella, not zoster. Cover lesions, avoid contact with pregnant non-immune women, neonates, immunocompromised until all lesions crusted.
— Hand hygiene, no sharing of towels/clothing
— Avoid scratching to prevent superinfection and scarring
— Sun protection over healed areas to reduce dyspigmentation
— Schedule Shingrix once recovered (immune to recurrence is partial, and vaccination after natural zoster is still recommended)
— Document varicella/zoster vaccine status for all adult patients
— Screen for depression (PHQ-9) at follow-up; PHN strongly associated with depression and suicidality
— Refer to behavioral health or initiate SSRI/SNRI (duloxetine doubles as analgesic) as appropriate
— Update problem list, allergy list, vaccine registry
— Communicate with PCP, ophthalmology, pain medicine as relevant
CCS pearl: On a CCS case, advance the clock 2 weeks and reassess pain and rash, then advance 3 months and screen for PHN, then document Shingrix scheduling — these longitudinal steps are scoring opportunities.
— Counsel patient about transmission risk to pregnant non-immune contacts, neonates, immunocompromised household members. Document the counseling.
— Healthcare workers with zoster: occupational health evaluation; cover lesions or remove from patient care depending on site and ability to cover; disseminated zoster → off work until all crusted.
— Discuss benefits (>90% efficacy), 2-dose requirement, common side effects (myalgia, fever, fatigue), and reactogenicity that can interfere with work
— Vaccine Information Statement (VIS) per National Childhood Vaccine Injury Act must be provided (also applies to adult vaccines administered under similar programs)
— Document refusal with informed refusal note
— Acyclovir/valacyclovir renal dosing errors at discharge are a known patient safety event — verify CrCl at discharge, especially in elderly with AKI
— Opioid + gabapentinoid combinations at discharge: FDA boxed warning for respiratory depression — minimize, counsel, consider naloxone
— Ensure ophthalmology follow-up is scheduled and confirmed before HZO discharge — visual loss after missed follow-up is a sentinel event
— Shingrix is covered by Medicare Part D (not Part B) — patients may face copays; check assistance programs
— Address language, health literacy, transportation for completing 2-dose series
— PHN can be disabling; assist with FMLA/short-term disability paperwork when indicated
— Zoster itself is not nationally reportable, but varicella (chickenpox) is reportable in most US states — relevant when a zoster index case infects a non-immune contact who then develops varicella
— Outbreaks in long-term care facilities should be reported per local health department
— Photograph lesions (with consent) for medicolegal documentation, especially in HZO and disseminated cases
— Document time of rash onset explicitly to justify antiviral decisions
Board pearl: A nursing home resident develops zoster. You must: cover lesions, use standard precautions (contact + airborne if disseminated/immunocompromised), notify infection control, and identify non-immune staff and residents for exposure assessment — a frequently tested infection-control item.
Key distinction: Primary varicella → airborne + contact precautions always. Localized zoster in immunocompetent host → standard precautions + cover lesions. Disseminated zoster OR any zoster in immunocompromised → airborne + contact precautions. This trio is heavily tested.
— Answer: Valacyclovir 1 g PO TID × 7 days; pain control; do not delay for testing.
— Answer: Same-day ophthalmology referral + oral valacyclovir (IV acyclovir if sight-threatening); Hutchinson sign.
— Answer: Acyclovir/valacyclovir neurotoxicity → hold drug, hydrate, dose-reduce; consider HD if severe.
— Answer: Offer HIV testing.
— Answer: PHN — start gabapentin or pregabalin, add topical lidocaine; nortriptyline as alternative.
— Answer: Shingrix, 2 doses IM 2–6 months apart, regardless of varicella history or prior zoster.
— Answer: Give Shingrix series (≥2 months after Zostavax).
— Answer: Admit, IV acyclovir, airborne + contact precautions.
— Answer: Valacyclovir is safe; counsel about non-immune contact precautions; defer Shingrix.
— Answer: Standard precautions + cover lesions; if disseminated or immunocompromised → airborne + contact.
— Answer: VZV vasculopathy; MRI/MRA; CSF anti-VZV antibody; IV acyclovir.
— Answer: No — steroids do not prevent PHN.
Step 3 management: When the stem provides time since rash onset, that number is doing work — <72 h means definite antivirals; >72 h with new lesions or any complication still means antivirals; >72 h all crusted and uncomplicated means symptomatic pain management only.
Herpes zoster is reactivated VZV producing a painful unilateral dermatomal vesicular rash that should be treated with oral valacyclovir within 72 hours of rash onset in immunocompetent adults, escalated to IV acyclovir for disseminated/visceral/CNS/severe-HZO/immunocompromised disease, managed long-term for postherpetic neuralgia with gabapentinoids, TCAs, or topical lidocaine, and prevented in all adults ≥50 (and immunocompromised ≥19) with the 2-dose recombinant Shingrix vaccine.
Board pearl: Three numbers anchor this topic on Step 3 — 72 hours (antiviral window), 90 days (PHN definition), and 2 doses (Shingrix completion). Memorize them, recognize them in stems, and your zoster questions become reflex answers.