What are the guideline sources, guidelines and references for Herpes zoster ?
Guideline sources The following summarized guidelines for the evaluation and management of herpes zoster (HZ) are prepared by our editorial team based on guidelines from the Center for Disease Control (CDC 2022; 2018), the German Herpes Management Forum (GHMF 2020), the American Society of Transplantation (AST 2019), the National Advisory Committee on Immunization (NACI 2018), the American Association of Family Physicians (AAFP 2017), the European Academy of Dermatology and Venereology (EADV/EDF 2017), the American College of Obstetricians and Gynecologists (ACOG 2015), and the Infectious Diseases Society of America (IDSA 2014). 1 2 3 4 5 6 7 8 9 10 Guidelines 1. Screening and diagnosis Diagnosis: diagnose HZ clinically without laboratory confirmation in patients with classical unilateral HZ of the thoracic or lumbar dermatomes. B https://web.pathway.md/diseases/recZEWlD6HYvbSJRU 1/9 6/24/23, 12:41 PM Herpes zoster Pathway 2. Diagnostic investigations Laboratory testing: As per GHMF 2020 guidelines, do not obtain laboratory confirmation in patients with HZ with a typical clinical presentation. Obtain laboratory confirmation in all other cases using VZV PCR or HSV-VZV PCR from swabs, aqueous humor, CSF, serum or plasma. D Show 5 more As per AAFP 2017 guidelines, obtain PCR of vesicle or other fluids for the diagnosis of HZ, if laboratory confirmation is needed, although HZ typically is diagnosed clinically. B As per EADV 2017 guidelines, consider obtaining viral antigen detection or molecular-based techniques (PCR) in patients with diagnostic uncertainty, particularly to distinguish HZ of the face and genital areas from zosteriform HSV-infection. C Show 4 more As per IDSA 2014 guidelines, consider obtaining peripheral blood PCR for VZV to help establishing the diagnosis of disseminated infection in patients with unexplained skin lesions. C HIV testing: As per GHMF 2020 guidelines, obtain testing for human immunodeficiency virus infection in < 50 years old patients with HZ. B As per EADV 2017 guidelines, obtain testing for human immunodeficiency virus infection in younger patients (possible cut-off 50 years of age) exhibiting widespread multidermatomal or recurrent HZ, particularly if lesions are simultaneously present in different disease stages and/or if other risk factors for human immunodeficiency virus seropositivity are present. B Neuroimaging: As per GHMF 2020 guidelines, obtain emergency MRI or CT in patients with neurological symptoms extending beyond cranial nerves VII and VIII or in patients with impaired consciousness. B As per EADV 2017 guidelines: Obtain acute MRI in patients with HZ and any neurological signs outside the VII and VIII nerves (such as a VI nerve palsy) or if there is any change in the level of consciousness. B Consider obtaining CT in patients with HZ with loss of > 2 points on the GCS. C Evaluation for complications: As per GHMF 2020 guidelines, assess for hemorrhagic/necrotic lesions, satellite lesions and aberrant vesicles, multisegmental or generalized cutaneous involvement, decreased overall health, and signs of meningism in all patients with HZ. B Show 3 more As per EADV 2017 guidelines, assess for the presence of hemorrhagic/necrotizing lesions, satellite lesions (aberrant vesicles), multisegmental or generalized cutaneous involvement, simultaneous presence of lesions in different developmental stages, altered general status and meningeal signs in patient presenting with HZ. B Show 3 more https://web.pathway.md/diseases/recZEWlD6HYvbSJRU 2/9 6/24/23, 12:41 PM Herpes zoster Pathway Evaluation for malignancy: As per GHMF 2020 guidelines, do not screen for malignancy in patients with HZ with a typical clinical course. D As per EADV 2017 guidelines, avoid obtaining investigations for cancer only based on the occurrence of HZ. D Assessment of pain: As per GHMF 2020 guidelines, distinguish between nociceptive and neuropathic pain. B Show 2 more As per EADV 2017 guidelines: Assess pain intensity by a validated pain assessment scale, such as VAS, NRS (0 = no pain, 10 = worst possible pain). B Consider assessing patient satisfaction with pain management (NRS: 0 = not satisfied to 10 = very satisfied). C 3. Diagnostic procedures Lumbar puncture: As per GHMF 2020 guidelines, ensure co-treatment by a neurologist and perform a lumbar puncture in patients with HZ-associated neurological symptoms. B As per EADV 2017 guidelines, perform lumbar puncture in patients with HZ with neurological symptoms and/or signs. B Biopsy: As per GHMF 2020 guidelines, perform a diagnostic biopsy (regular histology) in patients with atypical cutaneous manifestations, such as lichenoid, verrucous, granulomatous, and follicular lesions. B As per EADV 2017 guidelines, perform biopsy of lesions without ulceration and obtain a swab when ulceration is present in patients with atypical mucocutaneous manifestations including lichenoid, verrucous, granulomatous and follicular lesions. B 4. Medical management Systemic antiviral therapy: As per GHMF 2020 guidelines, initiate systemic antiviral therapy in patients with HZ with any of the following: age 50 years moderate-to-severe pain hemorrhagic or necrotic lesions aberrant vesicles/satellite lesions head and neck region involvement https://web.pathway.md/diseases/recZEWlD6HYvbSJRU 3/9 6/24/23, 12:41 PM Herpes zoster Pathway mucocutaneous involvement multisegmental involvement immunosuppression predisposing skin diseases (such as atopic dermatitis) pediatric and adolescent patients on long-term topical corticosteroid treatment. B Show 5 more As per AAFP 2017 guidelines, initiate acyclovir, valacyclovir, or famciclovir ideally within 72 hours of the appearance of the rash to decrease the duration of symptoms and severity of pain in patients with HZ. B As per EADV 2017 guidelines, initiate antiviral therapy in patients with: HZ of any localization and 50 years of age HZ of the head and/or neck area HZ of any localization with, moderate-to-severe zoster-associated pain, hemorrhagic or necrotizing lesions, > 1 segment involved, aberrant vesicles/satellite lesions, or involvement of mucous membranes HZ and immunocompromised states HZ and severe predisposing skin diseases (such as atopic dermatitis) HZ in pediatric and adolescent patients under long-term treatment with salicylic acid or corticosteroids. B Show 5 more As per IDSA 2014 guidelines: Initiate acyclovir in patients with suspected or confirmed cutaneous or disseminated VZV infection. B Add IV acyclovir to the antimicrobial regimen in patients with suspected or confirmed cutaneous or disseminated VZV infection. B Topical antiviral therapy: As per GHMF 2020 guidelines, do not use topical antiviral therapy for cutaneous HZ. D As per EADV 2017 guidelines, insufficient evidence to support the use of local antiviral preparations for the treatment of patients with cutaneous HZ. I Consider selecting a topical treatment according to the current status of the skin lesions. I Topical antiseptics: consider offering stage-adjusted topical treatment, including antiseptic gels for crusted vesicles, and cooling, anti-inflammatory or antiseptic solutions for fresh vesicles, in patients with HZ. C Management of herpes zoster ophthalmicus: As per GHMF 2020 guidelines, ensure co-treatment by an ophthalmologist to rule out ocular involvement in patients with HZ ophthalmicus. B Show 4 more As per EADV 2017 guidelines, initiate IV acyclovir as induction treatment (10 mg/kg bodyweight 3 /d for 7-10 days) followed by oral acyclovir (800 mg 5 /d for 3-4 months) in patients with https://web.pathway.md/diseases/recZEWlD6HYvbSJRU 4/9 6/24/23, 12:41 PM Herpes zoster Pathway acute retinal necrosis (as complication of HZ ophthalmicus). B Show 3 more Management of herpes zoster oticus: As per GHMF 2020 guidelines: Ensure co-treatment by an ENT specialist and a neurologist in patients with HZ oticus, particularly if there is facial nerve and/or vestibulocochlear nerve involvement. B Administer combination treatment consisting of IV acyclovir and systemic corticosteroids in patients with HZ oticus and facial nerve involvement (Ramsay Hunt syndrome), severe pain, and/or paralysis of multiple cranial nerves. B As per EADV 2017 guidelines, consider initiating combination therapy of IV acyclovir with systemic corticosteroids in patients with HZ oticus with involvement of the facial nerve (Ramsay Hunt syndrome) or with severe pain and multiple cranial nerve palsies. C Pain management, acute pain: As per GHMF 2020 guidelines, administer systemic analgesics for early treatment of HZ- associated pain. B Show 3 more As per EADV/EDF 2017 guidelines, administer early systemic analgesics for the treatment of acute zoster-associated pain. B Show 2 more Pain management, postherpetic neuralgia: As per GHMF 2020 guidelines, ensure co-treatment by a pain specialist in case of persistent pain despite pain management (4 weeks after the resolution of skin lesions). B As per AAFP 2017 guidelines: Offer capsaicin 8% patches applied for 30-90 minutes for pain relief in patients with postherpetic neuralgia. A Consider offering the following agents for pain relief in patients with postherpetic neuralgia: gabapentin pregabalin amitriptyline nortriptyline desipramine. B 5. Specific circumstances Pregnant patients: As per GHMF 2020 guidelines: Do not use systemic antiviral therapy during pregnancy in the absence of risk factors for a complicated disease course. D https://web.pathway.md/diseases/recZEWlD6HYvbSJRU 5/9 6/24/23, 12:41 PM Herpes zoster Pathway Initiate systemic antiviral therapy with acyclovir during pregnancy only for complicated disease courses. B As per EADV 2017 guidelines: Avoid using antiviral therapy in pregnant patients in the absence of the risk of complications. D Consider initiating antiviral therapy, preferably with acyclovir, in pregnant patients in the presence of risk factors for complicated courses of disease, if the potential benefits to the mother outweigh the potential risks to the fetus. C Pediatric patients: As per GHMF 2020 guidelines: Do not use systemic antiviral therapy in pediatric patients with HZ in the absence of risk factors for complications. D Consider initiating systemic antiviral therapy in pediatric patients with HZ in the presence of risk factors for a complicated disease course, if the therapeutic benefits outweigh any potential risks. C As per EADV 2017 guidelines: Avoid using antiviral therapy in pediatric patients in the absence of the risk of complications. D Consider initiating antiviral therapy in pediatric patients in the presence of risk factors for complicated courses of disease, if the potential benefits of the treatment outweigh the potential risks. C Patients with impaired renal function: As per GHMF 2020 guidelines: Assess creatinine levels at the initiation of oral antiviral therapy with acyclovir, famciclovir, or valacyclovir in patients with known or suspected CKD. B Administer oral brivudine (if oral antiviral treatment is indicated) or IV acyclovir (if intravenous antiviral treatment is indicated) at a dose adjusted to renal function in patients with impaired renal function. B As per EADV 2017 guidelines: Consider assessing creatinine levels in patients with known or suspected renal insufficiency at the time of initiation of antiviral therapy with acyclovir, famciclovir, or valacyclovir. C Administer oral brivudin (if oral antiviral therapy is indicated) or IV acyclovir with dosage adaptation (if IV treatment is indicated) in patients with renal function impairment. B Solid organ transplant recipients (screening for previous infection): obtain VZV serology during the pre-transplant evaluation to screen solid organ transplant candidates for prior VZV infection. B Solid organ transplant recipients (laboratory tests): obtain laboratory confirmation of HZ in solid organ transplant recipients, even though clinical presentations often allow for a presumptive clinical diagnosis. B Show 2 more https://web.pathway.md/diseases/recZEWlD6HYvbSJRU 6/9 6/24/23, 12:41 PM Herpes zoster Pathway Solid organ transplant recipients (antiviral therapy): administer IV acyclovir in post-transplant patients developing primary varicella, due to the risk of severe complications. B Show 4 more Solid organ transplant recipients (pre-transplant vaccination): administer the live-attenuated vaccine in VZV seronegative transplant candidates at least 4 weeks prior to transplantation, provided no contraindications are present. B Show 2 more Solid organ transplant recipients (post-transplant vaccination): Do not use the live-virus varicella vaccine in the post-transplant period. D Consider offering the live virus varicella vaccine with caution in selected seronegative patients receiving low level immunosuppression in the post transplant period. D Consider offering the adjuvanted subunit vaccine for the prevention of HZ in selected kidney transplant recipients at low risk for rejection. C Solid organ transplant recipients (post-transplant antiviral prophylaxis): Administer short-term prophylaxis with acyclovir or valacyclovir in HSV- and VZV-seropositive patients not receiving CMV prophylaxis (or receiving letermovir prophylaxis). A Administer short-term prophylaxis with acyclovir or valacyclovir in VZV-seropositive, HSV- seronegative patients not receiving CMV prophylaxis (or receiving letermovir prophylaxis). B Solid organ transplant recipients (post-exposure prophylaxis): administer post-exposure prophylaxis after a significant exposure in seronegative transplant recipients. A Show 2 more Solid organ transplant recipients (infection control): place all immunosuppressed patients admitted to the hospital with varicella or HZ on airborne and contact isolation precautions. B Show 2 more 6. Preventative measures Immunization, immunocompetent adults: As per CDC 2018 guidelines, offer recombinant zoster vaccine for the prevention of HZ in immunocompetent adults aged 60 years. E Show 9 more As per NACI 2018 guidelines, offer recombinant zoster vaccine in 50 years old adults without contraindications to the vaccine, including if previously vaccinated with zoster vaccine live A , or had a previous episode of HZ. B Show 3 more Immunization, immunocompromised adults: As per CDC 2022 guidelines, offer 2 doses of recombinant zoster vaccine in 19 years old immunocompromised patients, regardless of the previous history of HZ or previous receipt of zoster vaccine live. E Show 3 more https://web.pathway.md/diseases/recZEWlD6HYvbSJRU 7/9 6/24/23, 12:41 PM Herpes zoster Pathway As per CDC 2018 guidelines, offer recombinant zoster vaccine in patients taking low-dose immunosuppressive therapy (such as < 20 mg/day of prednisone or equivalent or using inhaled or topical corticosteroids) and patients anticipating immunosuppression or having recovered from an immunocompromising illness. E As per NACI 2018 guidelines, consider offering recombinant zoster vaccine (not zoster vaccine live) in 50 years old immunocompromised adults on a case-by-case basis. B Patient isolation: consider placing patients in a shared room with other patients with documented immunity to VZV if single-room isolation is not feasible and following an individual risk assessment. 7. Follow-up and surveillance Indications for referral: As per EADV 2017 guidelines, consult with an ophthalmologist for patients with HZ ophthalmicus to exclude complicated courses. B Show 2 more As per EADV 2017 guidelines, refer patients with persisting pain (such as after 4 weeks after the resolution of skin lesions) to a pain specialist. B Patients with resistant disease: Suspect clinical resistance of VZV infection if drug therapy failures after 10-21 days, particularly in patients presenting with verrucous VZV infection. B Consider obtaining VZV genotyping to provide information on the appearance of acyclovir or other antiviral resistant variants. C References 1. Gerd E Gross, Lisa Eisert, Hans Wilhelm Doerr et al. S2k guidelines for the diagnosis and treatment of herpes zoster and postherpetic neuralgia. J Dtsch Dermatol Ges. 2020 Jan;18 1 55 78. Open 2. Aaron Saguil, Shawn Kane, Michael Mercado et al. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. Am Fam Physician. 2017 Nov 15;96 10 656 663. Open 3. R N Werner, A F Nikkels, B Marinovi et al. European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum EDF in cooperation with the European Academy of Dermatology and Venereology EADV , Part 2 Treatment. J Eur Acad Dermatol Venereol. 2017 Jan;31 1 20 29. Open 4. Steven A Pergam, Ajit P Limaye, AST Infectious Diseases Community of Practice. Varicella zoster virus in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant. 2019 Sep;33 9):e13622. Open 5. R Warrington, S Ismail, National Advisory Committee on Immunization NACI . Summary of the NACI Update on Herpes Zoster Vaccines. Can Commun Dis Rep. 2018 Sep 6;44 9 220 225. Open https://web.pathway.md/diseases/recZEWlD6HYvbSJRU 8/9 6/24/23, 12:41 PM Herpes zoster Pathway 6. R N Werner, A F Nikkels, B Marinovi et al. European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum EDF in cooperation with the European Academy of Dermatology and Venereology EADV , Part 1 Diagnosis. J Eur Acad Dermatol Venereol. 2017 Jan;31 1 9 19. Open 7. Stevens DL, Bisno AL, Chambers HF et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59 2):e10 52. Open 8. Kathleen L Dooling, Angela Guo, Manisha Patel et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep. 2018 Jan 26;67 3 103 108. Open 9. No authors listed. Practice bulletin no. 151 Cytomegalovirus, parvovirus B19, varicella zoster, and toxoplasmosis in pregnancy. Obstet Gynecol. 2015 Jun;125 6 1510 1525. Open 10. Tara C Anderson, Nina B Masters, Angela Guo et al. Use of Recombinant Zoster Vaccine in Immunocompromised Adults Aged 19 Years: Recommendations of the Advisory Committee on Immunization Practices United States, 2022. MMWR Morb Mortal Wkly Rep. 2022 Jan 21;71 3 80 84. Open https://web.pathway.md/diseases/recZEWlD6HYvbSJRU 9/9