What is the best course of treatment for a patient presenting with a painful, raised rash on the arms consistent with herpes zoster (shingles), uncontrolled type 2 diabetes, hypokalemia, and nucleated red blood cells (NRBCs) on complete blood count (CBC)?

Treatment of Herpes Zoster with Multiple Comorbidities

Immediate Antiviral Therapy

Start valacyclovir 1 gram orally three times daily for 7 days immediately, continuing treatment until all lesions have completely scabbed. 1, 2, 3

• Valacyclovir is the first-line oral antiviral for uncomplicated herpes zoster in immunocompetent adults, with superior pain resolution compared to acyclovir and simpler dosing (three times daily vs. five times daily). 4, 1, 5
• Treatment is most effective when initiated within 72 hours of rash onset, but should still be administered even if presenting beyond this window, as observational data suggests benefit with later initiation. 1, 2, 6
• Continue therapy until all lesions have scabbed—this is the critical clinical endpoint, not an arbitrary 7-day duration. If active lesions persist beyond 7 days, extend treatment accordingly. 1, 2
• The FDA-approved dosing is 1 gram three times daily for 7 days for herpes zoster. 3

Escalation Criteria for IV Therapy

Monitor closely for signs requiring escalation to intravenous acyclovir 5-10 mg/kg every 8 hours: 4, 1, 2

• Multi-dermatomal involvement (disseminated disease)
• Visceral involvement
• Failure to respond to oral therapy within 48-72 hours
• Development of new lesions after 7 days of oral treatment
• Signs of CNS involvement

Important caveat: This patient's uncontrolled diabetes and prednisone use create relative immunosuppression, increasing risk of dissemination. 4 While not meeting criteria for IV therapy at presentation, maintain heightened surveillance.

Diabetes Management

Increase Ozempic from 0.5 mg to 1.0 mg weekly to improve glycemic control. [@patient plan@]

• Uncontrolled diabetes (elevated HgbA1c) increases risk of herpes zoster complications and impairs wound healing. 4
• Poor glycemic control can prolong viral shedding and delay lesion resolution in immunocompromised states. 4
• Repeat HgbA1c in 3 months to assess response.
• Continue home glucose monitoring throughout acute infection.

Electrolyte Correction

Start potassium chloride 20 mEq daily for documented hypokalemia. [@patient plan@]

• Hypokalemia is likely secondary to HCTZ (thiazide diuretic).
• Low potassium and chloride with elevated CO2 suggests contraction alkalosis from diuretic use.
• Monitor for symptoms of electrolyte imbalance including cardiac arrhythmias, muscle weakness, or cramping.
• Consider checking basic metabolic panel in 1-2 weeks to confirm correction.

Prednisone Consideration

Do not add systemic corticosteroids for herpes zoster treatment in this patient. 1

• The patient is already taking prednisone for joint pain, which may have contributed to VZV reactivation by causing relative immunosuppression. 4
• The CDC advises that prednisone should generally be avoided in immunocompromised patients with shingles due to increased risk of disseminated infection. 1
• While some guidelines suggest adjunctive prednisone may reduce acute pain in select severe cases, this patient's uncontrolled diabetes and existing immunosuppression from chronic steroid use are contraindications. 1
• Do not discontinue the patient's current prednisone abruptly (risk of adrenal insufficiency), but consider tapering after acute infection resolves in consultation with the prescribing provider.

Hematologic Abnormality Workup

Defer comprehensive evaluation of nucleated RBCs until after herpes zoster resolution. [@patient plan@]

• NRBCs on peripheral smear are concerning and require investigation, but acute viral infection can transiently cause their appearance.
• Once shingles resolve (approximately 2-4 weeks), order: [@patient plan@]
  • Peripheral blood smear review
  • Reticulocyte count
  • LDH and haptoglobin
  • Consider hematology referral pending results
• NRBCs may indicate hemolysis, bone marrow stress, severe anemia, or infiltrative marrow process—all requiring systematic evaluation once acute infection clears.

Pain Management

Provide topical analgesics for symptomatic relief of zoster-associated pain: [@patient plan@]

• Lidocaine patches or cream to affected areas
• Cool compresses for comfort
• Avoid topical antivirals (substantially less effective than systemic therapy). 1

For moderate to severe pain, consider:

• Acetaminophen or NSAIDs for mild pain
• Gabapentin or pregabalin if neuropathic pain develops
• Short-term opioids only if pain is severe and refractory

Infection Control Education

Counsel patient that lesions are contagious to varicella-susceptible individuals (those who have never had chickenpox or vaccination) until all lesions have crusted. [1, @patient plan@]

• Avoid contact with pregnant women, immunocompromised individuals, and infants until complete crusting occurs. 1
• Cover lesions with clothing or non-adherent dressings.
• Practice good hand hygiene.

Follow-Up Timeline

• 48-72 hours: Phone or in-person check to assess treatment response, ensure no new lesions forming, and confirm medication adherence
• 7-10 days: Evaluate for complete lesion crusting; extend valacyclovir if active lesions persist
• 2-4 weeks: Once lesions fully resolved, proceed with hematology workup for NRBCs
• 3 months: Repeat HgbA1c, reassess diabetes management, discuss sleep apnea evaluation

Vaccination After Recovery

Recommend recombinant zoster vaccine (Shingrix) after complete recovery from this acute episode. 1, 2

• The CDC recommends Shingrix for all adults aged 50 years and older regardless of prior herpes zoster episodes. 1, 2
• Vaccination can prevent future recurrences and is particularly important given this patient's risk factors (diabetes, chronic steroid use). 1
• Wait until acute infection completely resolves before administering vaccine (typically 2-4 weeks after all lesions have crusted).