When can individuals with shingles (varicella-zoster virus infection) return to work or school?

Return-to-Work Guidelines for Shingles (Herpes Zoster)

Individuals with shingles (herpes zoster) should remain excluded from work or school until all lesions have dried and crusted. 1

Return-to-Work Algorithm Based on Clinical Presentation

For Immunocompetent Individuals with Localized Herpes Zoster:

• If lesions can be completely covered:
  • May return to regular settings with lesions covered
  • Must avoid contact with high-risk individuals
  • Continue covering lesions until they are fully dried and crusted 1

For Immunocompromised Individuals OR Those with Disseminated Herpes Zoster:

• Complete exclusion from work/school required
• May return only when all lesions are dried and crusted 1
• This typically takes 7-10 days from rash onset 2

For Individuals with Lesions That Do Not Crust (macules and papules only):

• May return when no new lesions appear within a 24-hour period 1

Important Clinical Considerations

Timing of Lesion Evolution:

• Shingles rash typically evolves over 3-5 days with new vesicle formation
• Crusts persist for 2-3 weeks 2
• Pain may persist longer than the rash (post-herpetic neuralgia), especially in older adults 2

Treatment Impact:

• Early antiviral treatment (within 72 hours of rash onset) can shorten healing time 2
• Medications like valacyclovir or famciclovir can reduce the duration of viral shedding 3, 4
• However, even with treatment, the return-to-work criteria remain the same - all lesions must be dried and crusted 1

Special Populations and Settings

Healthcare Workers:

• Healthcare personnel with herpes zoster must follow stricter protocols:
  • With localized zoster and contained/covered lesions:
    • If vaccinated against varicella (≥1 dose): No work restrictions but must keep lesions covered
    • If unvaccinated: Restrict from patient contact until all lesions are crusted 1
  • With disseminated zoster or lesions that cannot be contained/covered:
    • Complete exclusion from duty until all lesions are dried and crusted 1

School Settings:

• Students with shingles should follow the same criteria as the general population
• All lesions must be dried and crusted before return 1
• For school-age children with lesions that can be completely covered, return may be permitted with strict adherence to keeping lesions covered

Common Pitfalls to Avoid

1. Premature return: Allowing return before lesions are fully crusted increases transmission risk
2. Inadequate covering of lesions: Even covered lesions can pose risk if not completely contained
3. Ignoring immunocompromised status: These individuals require stricter exclusion criteria
4. Confusing varicella (chickenpox) with herpes zoster guidelines: While related, they have different return criteria
5. Relying solely on antiviral treatment: While treatment speeds healing, it does not eliminate the need to wait for lesions to crust

Remember that shingles is caused by reactivation of the varicella-zoster virus, and while it is generally less contagious than primary varicella infection, it can still transmit the virus to susceptible individuals who may then develop chickenpox 5, 6.