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Herpes zoster

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of herpes zoster are prepared by our editorial team based on guidelines from the Center for Disease Control (CDC 2022,2018,2007), the German Herpes Management Forum (GHMF 2020), the American Society of Transplantation (AST 2019), the National Advisory Committee on Immunization (NACI 2018), the American Academy of Family Physicians (AAFP 2017), the ...
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Screening and diagnosis

Diagnosis: as per EADV/EDF 2017 guidelines, diagnose HZ clinically without laboratory confirmation in patients with classical unilateral HZ of the thoracic or lumbar dermatomes.
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Diagnostic investigations

Laboratory testing: as per GHMF 2020 guidelines, do not obtain laboratory confirmation in patients with HZ with a typical clinical presentation.
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obtain laboratory confirmation in all other cases using VZV PCR or HSV-VZV PCR from swabs, aqueous humor, CSF, serum or plasma.
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  • HIV testing

  • Neuroimaging

  • Evaluation for complications

  • Evaluation for malignancy

  • Assessment of pain

Diagnostic procedures

Lumbar puncture: as per GHMF 2020 guidelines, ensure co-treatment by a neurologist and perform a lumbar puncture in patients with HZ-associated neurological symptoms.
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  • Biopsy

Medical management

Systemic antiviral therapy: as per GHMF 2020 guidelines, initiate systemic antiviral therapy in patients with HZ with any of the following:
age ≥ 50 years
moderate-to-severe pain
hemorrhagic or necrotic lesions
aberrant vesicles/satellite lesions
head and neck region involvement
mucocutaneous involvement
multisegmental involvement
immunosuppression
predisposing skin diseases (such as atopic dermatitis)
pediatric and adolescent patients on long-term topical corticosteroid treatment.
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  • Topical antiviral therapy

  • Topical antiseptics

  • Management of HZ ophthalmicus

  • Management of HZ oticus

  • Pain management (acute pain)

  • Pain management (postherpetic neuralgia)

Specific circumstances

Pregnant patients
As per GHMF 2020 guidelines:
Do not use systemic antiviral therapy during pregnancy in the absence of risk factors for a complicated disease course.
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Initiate systemic antiviral therapy with acyclovir during pregnancy only for complicated disease courses.
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  • Pediatric patients

  • Patients with impaired renal function

  • Solid organ transplant recipients (screening for previous infection)

  • Solid organ transplant recipients (laboratory tests)

  • Solid organ transplant recipients (antiviral therapy)

  • Solid organ transplant recipients (pre-transplant vaccination)

  • Solid organ transplant recipients (post-transplant vaccination)

  • Solid organ transplant recipients (post-transplant antiviral prophylaxis)

  • Solid organ transplant recipients (post-exposure prophylaxis)

  • Solid organ transplant recipients (infection control)

Preventative measures

Immunization, immunocompetent adults: as per CDC 2018 guidelines, consider offering recombinant zoster vaccine in adults aged ≥ 50 years, irrespective of prior receipt of varicella vaccine or live zoster vaccine, and without screening for a history of chickenpox.
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  • Immunization (immunocompromised adults)

  • Patient isolation

Follow-up and surveillance

Indications for referral: as per EADV/EDF 2017 guidelines, consult with an ophthalmologist for patients with HZ ophthalmicus to exclude complicated courses.
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  • Patients with resistant disease