Herpes Zoster Airborne Precautions
Airborne precautions are required for disseminated herpes zoster and for immunocompromised patients with localized herpes zoster until dissemination is ruled out; immunocompetent patients with localized herpes zoster require only standard and contact precautions with complete lesion coverage. 1
Clinical Decision Algorithm
For Immunocompetent Patients with Localized Herpes Zoster (≤3 dermatomes):
- Standard and contact precautions only - airborne precautions are NOT required 2, 1
- Cover all lesions completely 1
- Maintain at least 6 feet physical separation from other patients 2
- Patient should wear a surgical mask to prevent droplet transmission 2
- Continue precautions until all lesions are dried and crusted (typically 4-7 days after rash onset) 1
For Disseminated Herpes Zoster (>3 dermatomes):
- Airborne AND contact precautions are mandatory 2, 1
- Negative air-flow room required 1
- Continue precautions until all lesions are dry and crusted 1
- This applies regardless of immune status 1
For Immunocompromised Patients with ANY Herpes Zoster:
- Airborne AND contact precautions required until disseminated infection is ruled out 2, 1
- Negative air-flow room required 1
- These patients experience prolonged viral shedding and slower healing (7-14 days or longer) 1
- Higher risk of disseminated infection 1
Rationale for Airborne Precautions in High-Risk Cases
The distinction exists because airborne transmission of varicella-zoster virus has been documented in healthcare settings, particularly affecting susceptible individuals with no direct contact with the index patient 1. While herpes zoster is approximately 20% as transmissible as chickenpox and primarily spreads through direct contact with lesion fluid, airborne spread can occur in hospitals 1. A documented outbreak involved three nurses who developed varicella after exposure to a patient with localized herpes zoster, providing evidence for airborne transmission risk 3.
Healthcare Worker Restrictions
- Immunocompetent healthcare workers with localized zoster: Cover all lesions completely and restrict from caring for high-risk patients (pregnant women, premature infants, immunocompromised persons) until all lesions are dried and crusted 1
- Healthcare workers with disseminated zoster or immunocompromised workers with localized zoster: Exclude from duty entirely until all lesions are dried and crusted 1
Common Pitfalls to Avoid
- Assuming localized zoster in immunocompetent patients requires airborne precautions - this leads to unnecessary resource utilization and room shortages 2, 1
- Failing to implement airborne precautions for immunocompromised patients with localized disease - these patients can develop disseminated infection and have documented airborne transmission 1, 3
- Inadequate lesion coverage - even with appropriate precaution level, uncovered lesions can transmit virus 1
- Allowing patient contact with high-risk individuals before complete crusting - viral shedding continues until all lesions are fully crusted, regardless of antiviral therapy 1