When should I consider referring a patient with herpes zoster for specialist evaluation?

Consider referring a patient with herpes zoster for specialist evaluation in the following situations:

• If serious complications such as meningitis, encephalitis, or myelitis are suspected.
• If the shingles involve the ophthalmic distribution of the trigeminal nerve, especially with Hutchinson's sign (rash on the tip, side, or root of the nose), eye pain, photophobia, reduced corneal sensitivity, visual impairment, or an unexplained red eye.
• If the head and neck are affected, particularly in elderly patients.
• If there are haemorrhagic or necrotic lesions, multisegmental involvement, aberrant vesicles or satellite lesions, mucosal involvement, or generalized herpes zoster.
• If the patient is severely immunosuppressed or an immunocompromised child has shingles.
• If there are signs of visceral or central nervous system involvement, including vasculitis.
• If new vesicles continue to form after 7 days of oral antiviral treatment or healing is delayed.
• If an immunocompetent person has had two episodes of shingles or if shingles recurs in an immunocompromised person.
• If pain is inadequately controlled by oral analgesia or if strong opioids are being considered.
• If the patient is pregnant or breastfeeding, seek specialist advice before prescribing antiviral treatment.

Use clinical judgment to decide the urgency and type of specialist referral (e.g., ophthalmology, dermatology, immunology, or pain specialist) based on the presenting problem and risk factors.

Severely immunocompromised patients should be referred for intravenous aciclovir treatment, while less severely immunosuppressed patients may be managed with oral antivirals under close follow-up.

Referral is also recommended if the diagnosis is uncertain or if there is inadequate response to treatment.