In an otherwise healthy adult presenting with fever and a herpes zoster eruption, what is the appropriate management?

Management of Fever with Shingles in Otherwise Healthy Adults

For an otherwise healthy adult presenting with fever and herpes zoster, initiate oral valacyclovir 1 gram three times daily for 7-10 days (or until all lesions have completely scabbed) within 72 hours of rash onset, and use over-the-counter analgesics for symptomatic fever control. 1, 2, 3

Initial Assessment and Risk Stratification

When evaluating fever with shingles, immediately assess the following critical factors:

• Count the number of dermatomes involved – involvement of more than 3 dermatomes indicates disseminated disease requiring IV therapy 3
• Evaluate timing of fever onset relative to rash appearance and whether antiviral therapy has already been initiated 3
• Examine for signs of visceral involvement including respiratory symptoms (pneumonitis), elevated liver enzymes (hepatitis), or neurological changes (encephalitis/meningitis) – any of these mandate escalation to IV acyclovir 3, 4
• Assess for bacterial superinfection by looking for purulence, expanding erythema beyond the dermatomal distribution, or warmth suggesting cellulitis 3

First-Line Antiviral Treatment for Uncomplicated Disease

For localized herpes zoster (≤3 dermatomes) in an immunocompetent adult with fever:

• Valacyclovir 1000 mg orally three times daily is the preferred first-line agent due to superior bioavailability and less frequent dosing 1, 2, 3
• Alternative: Acyclovir 800 mg orally five times daily if valacyclovir is unavailable 1, 2
• Alternative: Famciclovir 500 mg orally three times daily 2

Critical timing: Treatment must be initiated within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia 1, 2, 5

Treatment duration: Continue antiviral therapy until all lesions have completely scabbed – this is the key clinical endpoint, not an arbitrary 7-day period 1, 2, 3. Do not discontinue at exactly 7 days if lesions are still forming or have not completely crusted 2

Indications for Escalation to Intravenous Therapy

Switch to IV acyclovir 10 mg/kg every 8 hours if any of the following are present:

• Disseminated zoster (>3 dermatomes or visceral involvement) 1, 2, 3
• Signs of hepatitis, pneumonitis, or encephalitis 3, 4
• Complicated facial zoster with suspected CNS involvement 1
• Failure to respond to oral therapy within 7-10 days 2, 3
• Inability to tolerate or absorb oral medications 2

For IV therapy, continue for a minimum of 7-10 days and until clinical resolution is attained, then transition to oral therapy once clinical improvement occurs 1, 2

Symptomatic Management of Fever

For fever control in otherwise healthy adults:

• Over-the-counter analgesics such as acetaminophen or ibuprofen are recommended to relieve fever and acute pain 1
• Topical ice or cold packs can reduce pain and swelling during the acute phase 1
• Maintain adequate hydration throughout treatment 6

Avoid corticosteroids – while they may offer modest benefits for pain, they carry significant risks (infections, hypertension, myopathy, osteopenia) that do not outweigh benefits in most patients 1, 2

Monitoring During Treatment

• Assess renal function at baseline and monitor during therapy, particularly in elderly patients, with dose adjustments for creatinine clearance 3, 6
• If lesions fail to begin resolving within 7-10 days despite appropriate therapy, suspect acyclovir resistance and obtain viral culture with susceptibility testing 2, 3
• For confirmed acyclovir resistance, switch to foscarnet 40 mg/kg IV every 8 hours 1, 2

Infection Control Measures

• Patients should avoid contact with susceptible individuals (those who have not had chickenpox or vaccination) until all lesions have crusted 1, 2, 3
• Cover lesions with clothing or dressings to minimize transmission risk 1
• Standard precautions are sufficient for localized disease in immunocompetent patients 3

Common Pitfalls to Avoid

• Do not use topical antiviral therapy – it is substantially less effective than systemic therapy and is not recommended 1, 2
• Do not rely on a fixed 7-day treatment course – continue until all lesions have scabbed, which may take longer than 7 days 1, 2
• Do not delay treatment beyond 72 hours of rash onset, as efficacy diminishes significantly 2, 5
• Do not assume fever is always from the viral infection itself – bacterial superinfection is a recognized complication requiring additional antibiotic therapy 7, 3

Prevention of Future Episodes

After recovery from the current episode:

• The recombinant zoster vaccine (Shingrix) is strongly recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes 1, 2, 3
• Shingrix provides >90% efficacy in preventing future recurrences, superior to the older live attenuated vaccine 1, 3
• Administer the two-dose series after complete resolution of the current episode 1