The Lamb shift is always calculated from a Dirac equation for a single electron in a Coulomb field, with radiative corrections incorporated into a form factor due to the interaction with the quantized electromagnetic field - the vacuum is not involved at all.
The computation of the form factor at lowest order involves the evaluation of an integral corresponding to a Feynman diagram, and hence has (like any perturbative calculation in quantum field theory) an interpretation in terms of vacuum expectation values of the bare, unphysical, free theory. The latter is responsible for the misleading talks about vacuum fluctuations as if that were something physical.
On the other hand, vacuum polarization is a real physical contribution to the photon self-energy; it has almost nothing to do with the Lamb shift, contributing only a small fraction.