Zoster (Shingles)

B02.9

DESCRIPTION

Dermatomal eruption of vesicles on an erythematous base due to varicella-zoster virus (lies dormant in nerve ganglia following chickenpox).

GENERAL MEASURES

Isolate from immunocompromised or pregnant non-immune individuals (who may develop severe chickenpox).

Offer HIV test, especially in patients <50 years of age.

MEDICINE TREATMENT

Antiviral therapy, for:

  • zoster in immunocompromised patients, provided that active lesions are still being formed, and
  • in immunocompetent individuals provided they present within 72 hours of onset of clinical symptoms.
    • Antiviral (active against herpes zoster) e.g.:
    • Aciclovir, oral, 800 mg five times daily for 7 days (4 hourly missing the middle of the night dose).

LoEI [35]

For zoster with secondary dissemination or neurological/ eye involvement:

B02.7/B02.0-2†+(G02.0*/G05.1*/G53.0*/G63.0*)/ B02.3†+(H03.1*/H13.1*/H22.0*/H19.2*/ H19.0*)

  • Aciclovir, IV, 10 mg/kg administred over one hour 8 hourly for 7 days.
    • The course can be completed with aciclovir, oral, 800 mg five times daily.
    • Dose adjustment based on renal clearance

LoEIII [36]

See Aciclovir for guidance on prescribing and monitoring.

Secondary infection

B02.8

This is seldom present and is over-diagnosed. The vesicles in shingles often contain purulent material, and erythema is a cardinal feature of shingles. If there is suspected associated bacterial cellulitis:

  • Flucloxacillin, oral, 500 mg 6 hourly for 5 days.

For pain:

Pain is often very severe and requires active control. Combination of different classes of analgesics is often necessary.

Recommended therapy for acute phase of infection, e.g.:

  • Paracetamol, oral, 1 g 4–6 hourly when required.
    • Maximum dose: 15 mg/kg/dose.
    • Maximum daily dose: 4 g in 24 hours.

AND/OR

If pain is not adequately controlled:

  • Tramadol, oral, 50–100 mg 4–6 hourly.

See Pain, chronic

Post-herpetic neuralgia: B02.2+(G53.0*)

Initiate treatment with adjuvant therapy early.

  • Amitriptyline, oral, 25 mg at night.
    • Titrate as necessary to a maximum of 75 mg.

See Pain, chronic

REFERRAL

Refer to an ophthalmologist if there is ocular involvement with ophthalmic zoster (if the tip of the nose is involved then ocular involvement is much more likely). See Herpes zoster ophthalmicus .

Patients who develop complications e.g. myelitis.