Patient handout

Herpes zoster (shingles) — acute reactivation, complications & PHN

PRODUCTION

1. Your condition

This handout is for herpes zoster (shingles) — acute reactivation, complications & phn. Your care team identified this based on: unilateral grouped vesicles on erythematous base in a single dermatome, not crossing midline (cohen nejm 2013 — pathognomonic; dworkin cid 2007).

Other reasons your team may use this plan: burning/lancinating dermatomal pain or dysaesthesia preceding rash by 1–5 days (cohen nejm 2013 — preherpetic neuralgia); v1 (ophthalmic) rash, eyelid involvement, or vesicle on nasal tip/side (hutchinson sign) (liesegang ophthalmology 2008 — hzo emergency); vesicles in the ear canal/auricle/oral mucosa + peripheral facial palsy ± vertigo/hearing loss (ramsay hunt) (sweeney jnnp 2001).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
valacyclovir	1 g	PO	TID	Dworkin CID 2007 / Beutner AAC 1995 — preferred PO antiviral; higher bioavailability than acyclovir, faster zoster-associated pain resolution; ×7 days (10–14 d for HZO)
famciclovir	500 mg	PO	TID	Tyring Arch Fam Med 2000 — equivalent efficacy to acyclovir, TID dosing; ×7 days
acyclovir	800 mg	PO	5×/day	Dworkin CID 2007 — effective; preferred antiviral in pregnancy (most safety data); inconvenient 5×/day dosing; ×7–10 days
acyclovir (IV)	10 mg/kg	IV	q8h	Gershon 2015 / Dworkin CID 2007 — IV acyclovir 10 mg/kg q8h ×7–10 d for disseminated/visceral/CNS/sight-threatening or severely immunocompromised; ensure hydration to prevent crystal nephropathy
prednisone	60 mg taper	PO	once daily taper over 2–3 wk	Wood NEJM 1994 — adjunctive prednisone improves acute pain/QoL in selected immunocompetent adults and is used in Ramsay Hunt with antiviral; does NOT reduce PHN incidence; avoid in immunocompromise/uncontrolled DM/contraindications

Plan: Zoster antiviral by host & complication site

3. When to call your provider

Contact your care team if any of the following happen:

Any V1/Hutchinson + ocular symptom → emergent ophthalmology (Liesegang 2008)
Facial palsy + ear vesicles → Ramsay Hunt pathway, urgent ENT/neuro (Sweeney 2001)
>2 non-contiguous dermatomes / visceral / CNS → ED + IV acyclovir (Gershon 2015)
Severe immunocompromise → low admission threshold (Cohen NEJM 2013)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

V1 dermatome ± Hutchinson sign (nasociliary/nasal-tip vesicle) WITH ocular pain, redness, photophobia, or vision change (Liesegang Ophthalmology 2008; AAO HZO PPP)
Auricular/canal/oral vesicles + ipsilateral peripheral facial palsy ± vertigo/hearing loss (zoster oticus) (Sweeney JNNP 2001)
>2 non-contiguous dermatomes OR generalized vesicles beyond primary dermatome (>20 lesions outside) — disseminated VZV (Cohen NEJM 2013)(life-threatening)
Pneumonitis, hepatitis, encephalitis/meningitis, myelitis, or VZV vasculopathy (headache, confusion, focal deficit, stroke) (Gershon 2015)(life-threatening)
Zoster in HIV/transplant/chemotherapy/high-dose-steroid/biologic host (Cohen NEJM 2013; Dworkin CID 2007)
S2–S4 sacral zoster with urinary retention or bowel/bladder dysfunction (zoster-associated neurogenic bladder) (Cohen NEJM 2013)

5. Follow-up

PHN screen at ≥90 d (gabapentin/pregabalin → TCA (nortriptyline) → lidocaine 5% patch → capsaicin/opioid escalation); secondary prevention: 2-dose RZV (Shingrix) ≥50 routine and ≥19 immunocompromised — administer after acute episode resolves (Dworkin CID 2007; Rice Pain 2001; Dworkin Pain 2003; Dooling MMWR 2018; Anderson MMWR 2022)

6. Sources

Guideline: IDSA HSV-VZV management (Dworkin CID 2007) + Cohen NEJM 2013 clinical practice review + Gershon Nat Rev Dis Primers 2015 + ACIP RZV recommendations (Dooling MMWR 2018; Anderson MMWR 2022) + AAO Herpes Zoster Ophthalmicus PPP + CDC Shingles clinical guidance (current 2026 floor)