Herpes Zoster Infection in Adults

Publication: 20/10/2008  
Next review: 09/08/2024  
Clinical Guideline
ID: 1387 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.



  • Herpes zoster (Shingles) is a clinical manifestation of the reactivation of latent varicella zoster virus infection.
  • Diagnosis of herpes zoster is usually made by clinically assessing the patient for typical symptoms, which include:
    • Rash; usually a unilateral vesicular eruption in a dermatomal distribution.
    • Acute neuritis; usually in the same distribution as the rash. The pain may precede the onset of the rash, and may persist as post herpetic neuralgia.
  • Diagnosis can be more difficult in certain circumstances, for example:
    • Herpes simplex in the sacral or cervical areas may be difficult to distinguish clinically from herpes zoster.
    • Atypical manifestations can occur in immunocompromised patients including intermittently recurrent lesions, involvement of multiple dermatomes and lesions that appear as chronic crusts or nodules. Lesions may be widespread and the patient systemically unwell (disseminated herpes zoster).
  • If there is diagnostic uncertainty, a flock e-Swab for HSV, VZV and enterovirus PCR should be taken by removing the top from a lesion and swabbing the base. 

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Herpes zoster in the ophthalmic distribution of the trigeminal nerve should be referred to ophthalmology. Immunocompromised patients or those with complicated presentations (e.g. Ramsey Hunt syndrome) should be discussed with infectious diseases or virology.

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First line

Oral Switch


Immunocompetent patients2

Aciclovir PO 800mg five times daily

Use Aciclovir IV 10mg/kg3 8-hourly if neurological/ocular complications/head and neck vesicles


Aciclovir PO 800mg five times daily

7 days

Immunocompromised patients4

Aciclovir IV 10mg/kg3 8-hourly

Valaciclovir PO 1g 8-hourly

Minimum course 10 days. Continue until 48 hours after crusting of lesions

  • Consider oral switch from IV aciclovir as per above table if patient is systemically well and no new vesicles have appeared for 24 hours.
  • Oral treatment with close observation may be appropriate first-line in certain immunosuppressed patients. In this situation, valaciclovir should be used. This should be discussed on a case-by-case basis with the clinical team responsible for immunosuppression (e.g. haematology, rheumatology). The decision to use oral therapy should take into account the severity of herpes zoster and the nature of immunosuppression, including expected impairment to cell-mediated immunity.
  • Recurrent shingles in immunocompetent or immunocompromised patients should be discussed with an infection specialist.

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  • Follow the WHO analgesic ladder to treat pain in Herpes Zoster. Note that agents to treat neuropathic pain (such as gabapentin and pregabalin) may be required.
  • Chlorphenamine orally can be used to relieve itch.
  • Corticosteroids are not indicated routinely in uncomplicated herpes zoster. They may be indicated in patients with severe pain or involvement of cranial nerves, however this should be discussed with infectious diseases or virology.

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Herpes zoster vaccine is offered routinely to all people at age 70 years with the aim of lowering the incidence and severity of herpes zoster in older people.  The vaccine is live attenuated and should not be given to immunosuppressed individuals without a prior clinical risk assessment. In immunocompetent individuals who develop herpes zoster, vaccination should be delayed for one year.

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  • Patients with herpes zoster on exposed areas (e.g. face or eye) or those with a disseminated rash should be placed in source isolation until crusting of all lesions.
  • In wards containing immunocompromised patients (e.g. haematology / oncology), all patients with herpes zoster should be placed in source isolation (negative or neutral pressure) regardless of the location of the lesions.
  • Contact the IPC team for further advice.

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  • Longer durations may be needed for those with ocular or neurological complications.
  • For immunocompetent patients, antiviral treatment should ideally be started within 72 hours of rash onset but can be considered after this if new vesicles are forming.
  • Use ideal body weight to calculate dosing in obese patients. For underweight patients use actual body weight.  
  • All immunocompromised patients should receive antivirals.


Record: 1387
Clinical condition:

Herpes zoster

Target patient group: Adults with suspected herpes zoster infection (shingles)
Target professional group(s): Secondary Care Doctors
Adapted from:

Evidence base

  • Whitley RJ, Weiss H, Gnann JW Jr, et al. Acyclovir with and without prednisone for the treatment of herpes zoster: a randomized, placebo-controlled trial. Ann Intern Med 1996; 125:376–83.
  • Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med 1994; 330:896–900
  • He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2008
  • Dworkin RH, Schmader KE. Treatment and prevention of postherpetic neuralgia. Clin Infect Dis 2003; 36:877–82.
  • Dworkin RH, Barbano RL, Tyring SK, Betts RF, McDermott MP, Pennella-Vaughan J, et al. A randomized, placebo-controlled trial of oxycodone and of gabapentin for acute pain in herpes zoster. Pain. 2009 Apr;142(3):209-17
  • Rice ASC, Maton S. Gabapentin in postherpetic neuralgia: a randomised, double blind, placebo controlled study. Pain 2001; 94:215–24.
  • Dworkin RH, Johnson RW et al. Recommendations for the management of herpes zoster. Clin infect Dis 2007;44:S1-26
  • Wood MJ, Kay R, Dworkin RH, Soong SJ, Whitley RJ. Oral acyclovir therapy accelerates pain resolution in patients with herpes zoster: a meta-analysis of placebo-controlled trials. Clin Infect Dis 1996; 22:341–7.
  • Jackson JL, Gibbons R, Meyer G, Inouye L. The effect of treating herpes zoster with oral acyclovir in preventing postherpetic neuralgia: a meta-analysis. Arch Intern Med 1997; 157:909–12.
  • Crooks RJ, Jones DA, Fiddian AP. Zoster-associated chronic pain: an overview of clinical trials with acyclovir. Scand J Infect Dis Suppl 1991; 78:62–8.
  • McKendrick MW, McGill JI, White JE, Wood MJ. Oral acyclovir in acute herpes zoster. BMJ 1986; 293: 1529 – 32.
  • Huff JC, Bean B, Balfour HH Jr, et al. Therapy of herpes zoster with oral acyclovir. Am J Med 1988; 85 (Suppl 2A): 84 – 9.
  • Huff JC, Drucker JL, Clemmer A, et al. Effect of oral acyclovir on pain resolution in herpes zoster: a reanalysis. J Med Virol 1993; Suppl 1:93 – 6.
  • Wood MJ, Organ PH, McKendrick MW, Care CD, McGill JI, Webb EM. Efficacy of oral acyclovir treatment of acute herpes zoster. Am J Med 1988; 85(Suppl 2A): 79 – 83.
  • Morton P, Thomson AN. Oral acyclovir in the treatment of herpes zoster in general practice. N Z Med J 1989; 102: 93 – 5.
  • Beutner KR, Friedman DJ, Forszpaniak C, Andersen PL, Wood MJ. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother 1995; 39:1546–53.
  • Serota FT, Starr SE, Bryan CK, Koch PA, Plotkin SA, August CS. Acyclovir treatment of herpes zoster infections use in children undergoing bone marrow transplant. JAMA 1982; 247:2132–6.
  • Shepp DH, Dandliker PS, Meyers JD. Treatment of varicella-zoster infection in severely immunocompromised patients: a randomized comparison of acyclovir and vidarabine. N Engl J Med 1986; 314:208–12.
  • Meyers JD, Wade JC, Shepp DH, Newton B. Acyclovir treatment of varicella-zoster virus infection in the compromised host. Transplantation 1984; 37:571–4.
  • Brentjens MH, Torres G, He J, Lee PC, Tyring SK. A double-blind randomized study of the use of 2 grams vs. 1 gram valacyclovir TID for 7 days in the treatment of acute herpes zoster in immunocompromised individuals. Presented at: Annual Meeting of the American Academy of Dermatology (San Francisco, March 2003).
  • Public Health England. The Green Book: Chapter 28a Shingles (herpes zoster). February 2016
  • Werner, RN et al. 2017. European consensus-based (S2k) Guideline on the Mnaagement of Herpes Zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 2: Treatment. Journal of the European Academy of Derematology and Verereology. 31: 20-29

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

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