What questions should be asked and what management is recommended for a patient with suspected shingles?

Questions to Ask and Management for Suspected Shingles

The most important questions to ask a patient with suspected shingles focus on pain characteristics, rash distribution, and risk factors, followed by prompt antiviral treatment within 72 hours of rash onset to reduce complications.

Key Questions for Assessment

Pain and Sensory Symptoms

• Ask about pain, burning, tingling, or itching in a localized area that preceded the rash (prodromal symptoms) 1
• Determine if pain is unilateral and confined to a specific dermatome 2
• Assess pain severity and character (sharp, burning, aching) 2

Rash Characteristics

• Ask when the rash first appeared (timing is critical as antivirals are most effective within 72 hours) 2
• Determine if the rash follows a dermatomal distribution (typically unilateral and doesn't cross midline) 1
• Ask about progression of the rash (maculopapular → vesicular → crusting) 1

Risk Factors and Medical History

• Ask about history of chickenpox (varicella) infection 1
• Inquire about immune status (HIV, cancer, immunosuppressive medications) as immunocompromised patients are 20-100 times more likely to develop shingles 2
• Ask about recent stressors, illness, or procedures that might trigger reactivation 3

Constitutional Symptoms

• Ask about fever, malaise, headache, or other systemic symptoms that may have preceded the rash 2
• Inquire about any associated neurological symptoms 1

Management Recommendations

Antiviral Therapy

• Initiate antiviral therapy as soon as possible, ideally within 72 hours of rash onset 2
• Recommended regimens include:
  • Acyclovir 800 mg orally five times daily for 7-10 days 4
  • Valacyclovir 1 g orally three times daily for 7 days 3
  • Famciclovir 500 mg orally three times daily for 7 days 2

Pain Management

• For acute pain, use appropriate analgesics based on pain severity 1
• NSAIDs like ibuprofen may be sufficient for mild to moderate pain 3
• For severe pain, consider short-term opioid analgesics 2

Prevention of Complications

• Monitor for signs of secondary bacterial infection of lesions 1
• Watch for involvement of the ophthalmic branch of the trigeminal nerve (requires urgent ophthalmology referral) 1
• Counsel patients about the risk of postherpetic neuralgia, especially in older adults 5

Special Populations

• For immunocompromised patients:
  • Monitor more closely as they may develop more severe disease with potential for dissemination 1
  • Consider longer duration of antiviral therapy 1
• For pregnant women:
  • Shingles during pregnancy usually has a mild course but requires careful monitoring 1
  • VZIG is recommended for VZV-susceptible pregnant women within 96 hours after exposure to VZV 4

Patient Education

• Advise patients that shingles lesions contain live virus and can transmit chickenpox to susceptible individuals 1
• Recommend covering lesions until they crust over 1
• Explain that adequate hydration should be maintained during antiviral therapy 6
• Inform patients that early treatment can reduce the risk of postherpetic neuralgia 2

Follow-up

• Schedule follow-up to assess healing and monitor for complications 2
• For patients who develop postherpetic neuralgia, consider treatments such as gabapentin, pregabalin, or tricyclic antidepressants 2

Red Flags Requiring Urgent Attention

• Ophthalmic involvement (eye pain, redness, or visual changes) 1
• Widespread dissemination beyond a single dermatome, especially in immunocompromised patients 1
• Neurological deficits or altered mental status suggesting CNS involvement 1
• Severe pain unresponsive to standard analgesics 5