What is the immediate post-outbreak plan of care for an adult patient, possibly with a compromised immune system or of advanced age, who has had shingles?

Post-Shingles Plan of Care

Continue antiviral therapy until all lesions have completely scabbed, monitor for postherpetic neuralgia development, and administer the recombinant zoster vaccine (Shingrix) after recovery to prevent future recurrences. 1

Immediate Post-Outbreak Management

Complete the Antiviral Course

• Treatment must continue until all lesions have completely scabbed, not just for an arbitrary 7-day period 1
• For immunocompetent patients on oral antivirals (acyclovir 800mg 5x daily, valacyclovir 1000mg 3x daily, or famciclovir 500mg 3x daily), extend therapy beyond 7-10 days if lesions remain active 1, 2
• Immunocompromised patients may require treatment extension well beyond 7-10 days as their lesions continue to develop over longer periods (7-14 days) and heal more slowly 1
• If on IV acyclovir (10 mg/kg every 8 hours), continue for minimum 7-10 days and until clinical resolution is attained 1

Monitor for Treatment Failure

• If lesions fail to begin resolving within 7-10 days, suspect acyclovir resistance and obtain viral culture with susceptibility testing 1
• For confirmed acyclovir resistance, switch to foscarnet 40 mg/kg IV every 8 hours until clinical resolution 1, 3
• Monitor renal function at initiation and once or twice weekly during IV acyclovir treatment 1

Infection Control and Skin Care

Prevent Transmission

• Patients must avoid contact with susceptible individuals (pregnant women, immunocompromised persons, unvaccinated children) until all lesions have crusted 1
• Lesions are contagious to individuals who have not had chickenpox, as vesicle fluid contains enormous amounts of virus particles 4

Wound Care

• Keep the affected area clean and dry to prevent secondary bacterial infection 4, 5
• After lesions have crusted, emollients may be used to prevent excessive dryness, but avoid applying any products to active vesicular lesions 1
• Elevation of the affected area (particularly for facial involvement) promotes drainage of edema and inflammatory substances 1

Pain Management and Postherpetic Neuralgia Prevention

Acute Pain Control

• Continue analgesics as needed for acute neuritis during the healing phase 4, 5
• For severe pain, consider gabapentin, pregabalin, or tricyclic antidepressants (amitriptyline) even during the acute phase 5, 6
• Topical lidocaine patches may provide relief once lesions have crusted 6

Monitor for Postherpetic Neuralgia

• Postherpetic neuralgia is defined as pain in a dermatomal distribution sustained for at least 90 days after acute herpes zoster 2
• This occurs in approximately one in five patients and is more common in elderly and immunocompromised individuals 2, 7
• Early antiviral treatment (within 72 hours of rash onset) reduces the risk of postherpetic neuralgia 2, 5

Treatment of Established Postherpetic Neuralgia

• First-line options include gabapentin, pregabalin, tricyclic antidepressants, lidocaine patch 5%, or capsaicin 6
• Opioids may be required for adequate pain control in refractory cases 5, 6
• For treatment-refractory postherpetic neuralgia, consult a pain-management specialist and consider nonpharmacologic approaches 6

Vaccination for Secondary Prevention

Recombinant Zoster Vaccine (Shingrix)

• The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes, to prevent future recurrences 1, 3
• This vaccine can be considered after recovery from the acute episode 1
• Shingrix is preferred over the live attenuated vaccine (Zostavax), especially for immunocompromised patients 1
• Vaccination should ideally occur before initiating immunosuppressive therapies when possible 1

Special Populations Requiring Extended Monitoring

Immunocompromised Patients

• HIV-infected individuals and other immunocompromised patients are at higher risk for recurrent shingles 3
• Consider daily suppressive therapy with acyclovir 400 mg orally twice daily, famciclovir 250 mg orally twice daily, or valacyclovir 500-1000 mg once daily for patients with frequent or severe recurrences 3
• Safety and efficacy of acyclovir documented for up to 6 years of continuous use 3
• Reassess the need for continued suppressive therapy after 1 year 3

Pregnant Women

• VZIG is recommended for VZV-susceptible pregnant women within 96 hours after exposure to VZV 8, 9
• If oral acyclovir is used during pregnancy, VZV serology should be performed to determine if the patient is already seropositive 9

Patients with Ophthalmic Involvement

• Ophthalmic complications (keratitis, iridocyclitis, secondary glaucoma, loss of sight) require ongoing ophthalmology follow-up 4
• These patients generally merit referral to an ophthalmologist for continued monitoring 5

Common Pitfalls to Avoid

• Do not discontinue antiviral therapy at exactly 7 days if lesions are still forming or have not completely scabbed 1
• Do not use topical antivirals, as they are substantially less effective than systemic therapy 1, 9
• Do not apply corticosteroid creams to active shingles lesions, as this can increase the risk of severe disease and dissemination, especially in immunocompromised patients 1
• Do not assume a single episode means immunity—recurrence is possible, particularly in immunocompromised individuals 3, 7
• Do not delay vaccination after recovery; Shingrix can be administered once the acute episode has resolved 1