Patient handout

Varicella zoster virus disease — primary varicella + herpes zoster + PHN + complications + RZV vaccination eligibility

PRODUCTION

1. Your condition

This handout is for varicella zoster virus disease — primary varicella + herpes zoster + phn + complications + rzv vaccination eligibility. Your care team identified this based on: generalized vesicular rash in successive crops (papule → vesicle → pustule → crust) + fever + pruritus — primary varicella (gershon nat rev dis primers 2015 pmid 27188665; aap red book 2024).

Other reasons your team may use this plan: dermatomal vesicular rash + neuritic pain along single dermatome (occasionally 2-3 contiguous) — herpes zoster (cohen nejm 2013 pmid 23863052); vesicle on nasal tip (hutchinson sign) in v1 distribution — ophthalmic zoster (hzo) with corneal-involvement risk → emergent ophthalmology (aao hzo ppp; cohen nejm 2013); facial palsy + ear vesicles + auricular pain ± auditory/vestibular features — ramsay hunt syndrome (zoster oticus) (sweeney jnnp 2001; dworkin cid 2007 pmid 17143845).

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
acetaminophen	10-15 mg/kg/dose q4-6h PRN (max 75 mg/kg/d)	PO	q4-6h PRN	Acetaminophen preferred — AVOID aspirin (Reye syndrome); AVOID ibuprofen (emerging necrotising fasciitis signal with secondary streptococcal infection per AAP) (AAP Red Book 2024)

Plan: VZV antiviral therapy — by phenotype (primary varicella / zoster / severe / HZO / Ramsay Hunt / disseminated / pregnant / neonatal)

3. When to call your provider

Contact your care team if any of the following happen:

New neuro signs (focal deficits, seizures, encephalopathy) → urgent ED + MRI + LP + IV acyclovir
New respiratory distress / oxygen level (SpO₂) < 94% → urgent ED + CXR + IV acyclovir
New ocular pain / vision change → emergent ophthalmology
New systemic toxicity / disseminated rash → urgent ED + ID + IV acyclovir
Severe refractory PHN ≥ 6 mo → pain medicine + neurology + consider nerve block / neurostimulation
Immunocompromise emergence (new HIV diagnosis, transplant, chemo, high-dose steroid initiation) → re-evaluate antiviral threshold + RZV vaccination planning

4. When to seek emergency care

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

Disseminated zoster (> 20 lesions outside primary + 2 adjacent dermatomes) OR VZV pneumonitis (oxygen level (SpO₂) < 94% + diffuse infiltrates on CXR) — life-threatening; IV acyclovir 10 mg/kg q8h × 7-14 d + ICU + ID consult; bacterial co-empirics until alternative source excluded if sepsis-like (Gilden CID 2021 PMID 32856043; AAP Red Book 2024)(life-threatening)
VZV encephalitis (altered mental status, seizures, focal deficits + CSF lymphocytic pleocytosis + positive VZV PCR OR intrathecal antibody index) OR VZV vasculopathy (focal neuro deficits + stroke pattern on MRI + recent zoster + positive CSF VZV PCR or antibody index) — life-threatening; IV acyclovir 15 mg/kg q8h × 14 d + steroids for vasculopathy + neurology + ID (Gilden CID 2021 PMID 32856043; IDSA HSV-VZV)(life-threatening)
Vesicle on nasal tip (Hutchinson sign) in V1 trigeminal distribution — corneal-involvement risk (nasociliary branch V1); EMERGENT ophthalmology + oral valacyclovir 1 g TID × 7-10 d + topical antiviral (trifluridine or ganciclovir gel) + slit-lamp / IOP / fluorescein staining; lifetime ocular complications (keratitis, uveitis, glaucoma) (AAO HZO PPP; Cohen NEJM 2013 PMID 23863052)
Facial palsy + ear vesicles + auricular pain ± auditory/vestibular features — zoster oticus; oral valacyclovir 1 g TID × 7-10 d + prednisone 60 mg/d × 5 d then taper; neurology + ENT consult; facial recovery prognosis worse than Bell palsy idiopathic (~ 40% complete recovery vs ~ 70%) (Sweeney JNNP 2001; Dworkin CID 2007 PMID 17143845)
Susceptible pregnant patient (any trimester) exposed to varicella within 96 h (CDC expanded to 10 d) — VariZIG 125 IU per 10 kg (max 625 IU) IM + VZV IgG serology testing; if active disease, treat per phenotype (oral acyclovir if mild / IV acyclovir if severe pneumonitis); congenital varicella syndrome risk ~ 1-2% if maternal varicella in first 20 wk gestation; vaccination CONTRAINDICATED in pregnancy (ACOG; AAP Red Book 2024; CDC VariZIG guidance)
Maternal varicella 5 d pre to 2 d post delivery — life-threatening neonatal varicella (mortality up to 30% without VariZIG); VariZIG immediately + IV acyclovir 10 mg/kg q8h if symptomatic + NICU admission + ID consult; bacterial co-empirics until alternative source excluded (AAP Red Book 2024; CDC VariZIG guidance)(life-threatening)
Zoster or primary varicella in immunocompromised (HIV CD4 < 200, transplant within 1 yr OR ongoing immunosuppression, chemo cycle nadir, chronic high-dose steroid ≥ 20 mg prednisone-equivalent × ≥ 1 mo, autoimmune on biologic) — IV acyclovir 10 mg/kg q8h × 7-14 d + ID consult; foscarnet 40 mg/kg q8h IV rescue if acyclovir resistance suspected; risk of dissemination, pneumonitis, encephalitis, hepatitis, IRIS especially in HIV / transplant (AAP Red Book 2024; IDSA HSV-VZV)

5. Follow-up

Post-zoster: PHN surveillance at 1 mo, 3 mo (PHN diagnostic threshold), 6 mo; pain medicine + neurology if refractory. Post-HZO: ophthalmology lifetime follow-up for keratitis / uveitis / glaucoma recurrence. Post-Ramsay Hunt: facial recovery tracking (~ 40% complete recovery vs ~ 70% for Bell palsy) + audiology + ENT. Post-vasculopathy: stroke prevention + cerebrovascular follow-up. Vaccination reconciliation: RZV 2-dose ≥ 50 routine / ≥ 19 immunocompromised; varicella vaccine 2-dose susceptible adult catch-up; pediatric 2-dose schedule audit (12-15 mo + 4-6 yr). Family education + contact tracing if institutional outbreak; report to public health if needed.

6. Sources

Guideline: CDC ACIP — Recombinant Zoster Vaccine (RZV/Shingrix) (Dooling MMWR 2018 + Anderson MMWR 2022 immunocompromised) + CDC ACIP Varicella vaccination (Marin MMWR 2007) + AAP Red Book current edition (2024 + 2026 floor) Varicella + Herpes Zoster chapters + IDSA HSV-VZV consensus / Dworkin CID 2007 + Cohen NEJM 2013 Herpes Zoster review + Gershon Nat Rev Dis Primers 2015 Varicella Zoster Virus Infection + Gilden/Ansari CID 2021 severe VZV CNS vasculopathy + Lal NEJM 2015 ZOE-50 + Cunningham NEJM 2016 ZOE-70 + ACOG Practice Advisory Varicella in Pregnancy + AAO HZO Preferred Practice Pattern + CDC VariZIG guidance