Zoster (Shingles)

Description

General measures

Medicine treatment

Referral

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ICD-10 code: 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 should be provided for:

• Immunocompromised patients, provided that active lesions are still being formed, and
• 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 (given 4 hourly except for the dose scheduled for the middle of the night).

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For zoster with secondary dissemination or neurological/ complicated eye involvement (i.e. complicated herpes zoster ophthalmicus e.g. acute retinal necrosis (ARN), optic neuropathy or orbitopathy):
ICD-10 code: B02.0-3 †+(H03.1*/H13.1*/H19.2*/H19.0*/H22.0*)/ B02.7+(G02.0*/G05.1*/G53.0*/ G63.0*)/B02.8

• Aciclovir, IV, 10 mg/kg 8 hourly for 7 days.
  • Infuse aciclovir over one hour.
  • The course can be completed with aciclovir, oral, 800 mg five times daily.
  • Dose adjustment based on renal clearance (See: Prescribing and monitoring).

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Secondary infection
ICD-10 code: 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, 500 mg -1 g 4–6 hourly when required (to a maximum of 4 g in 24 hours).
  • Maximum dose: 15 mg/kg/dose.

AND/OR

If pain is not adequately controlled:

• Tramadol, oral, 50–100 mg 6 hourly.

See: Pain.

Post-herpetic neuralgia:
ICD-10 code: B02.2+(G53.0*)

Initiate adjuvant therapy early if indicated.

• Amitriptyline, oral, 10 mg at night.
  • Titrate as necessary to a maximum dose of 150 mg.

See: Neuropathic pain.

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.

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.2_20 January 2025

Chapter 9 Systemic and Healthcare-Associated Infections_9.13 Zoster (Shingles)