Hospital Admission Criteria for Patients with Suspected Shingles
Patients with suspected shingles should be hospitalized if they have severe immunocompromise, multidermatomal involvement, ophthalmic involvement, or signs of disseminated disease, as these conditions significantly increase morbidity and mortality risks. 1
Specific Indications for Hospital Admission
Immunocompromised Patients
- Patients with malignancy on chemotherapy
- Neutropenia
- Severe cell-mediated immunodeficiency (e.g., HIV/AIDS)
- Transplant recipients on immunosuppressive medications
- Patients on chronic corticosteroid therapy 1
Clinical Manifestations Requiring Admission
- Disseminated cutaneous infection (lesions outside the primary or adjacent dermatomes)
- Ophthalmic involvement (herpes zoster ophthalmicus)
- Multidermatomal involvement
- Severe pain uncontrolled by oral medications
- Inability to take oral medications due to nausea/vomiting 1, 2
Neurological Complications
- Signs of meningoencephalitis (altered mental status, headache with neck stiffness)
- Motor neuropathies
- Cranial nerve palsies 2
Systemic Illness
- Systemic Inflammatory Response Syndrome (SIRS)
- Hemodynamic instability
- Altered mental status 1
Special Populations
Elderly Patients
Elderly patients (>65 years) have higher risk for complications and should be considered for admission with:
- Moderate to severe pain
- Extensive rash
- Significant comorbidities
- Poor social support 2
Pregnant Women
Pregnant women with shingles should be evaluated for possible admission, especially in the third trimester, due to risk of:
- Vertical transmission
- Complications affecting pregnancy 2
Outpatient Management Criteria
Patients suitable for outpatient management include those with:
- Limited dermatomal involvement
- Normal immune function
- Adequate pain control with oral medications
- No signs of systemic illness
- Reliable follow-up and social support 1, 3
Treatment Considerations
Inpatient Treatment
- High-dose intravenous acyclovir (10 mg/kg every 8 hours)
- Pain management with appropriate analgesics
- Monitoring for complications 4
Outpatient Treatment
- Oral antiviral medications (acyclovir, valacyclovir, or famciclovir)
- Most effective when started within 72 hours of rash onset
- Pain management with appropriate analgesics 4
Follow-up Recommendations
- Patients treated as outpatients should be reassessed within 48-72 hours to evaluate treatment response 3
- Patients discharged after hospitalization should follow up within 1-2 weeks
Common Pitfalls to Avoid
- Failing to recognize disseminated zoster in immunocompromised patients
- Overlooking ophthalmic involvement (which requires urgent ophthalmology consultation)
- Underestimating pain severity and need for adequate analgesia
- Delaying antiviral therapy beyond 72 hours of rash onset 4, 2
Remember that early recognition and appropriate triage of patients with shingles who require hospitalization can significantly reduce morbidity, mortality, and the risk of long-term complications such as postherpetic neuralgia.