eMedicine Specialties > Infectious Diseases > Viral Infections
Herpes Zoster: Treatment & Medication
Updated: May 1, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Acute herpes zoster
As described above, episodes of herpes zoster are generally self-limited and resolve without intervention. However, effective treatments do exist and can reduce the extent and duration of symptoms as well as the risk of chronic sequelae (ie, postherpetic neuralgia). Treatment is of most benefit in those patient populations at risk for prolonged or severe symptoms, specifically immunocompromised people and those older than 50 years. The benefit of treating younger and healthier populations is unclear.
- Topical therapy: The pain and pruritus of zoster can be reduced through judicious use of cool water compresses or baths, as well as the application of over-the-counter lotions containing calamine and other analgesic or antipruritic compounds.
- Analgesics
- Topical, intradermal, and systemic analgesics may provide relief from the discomfort caused by zoster. Depending on the severity of symptoms, necessary medication may range from basic analgesics such as acetaminophen to powerful narcotic agents.
- Dworkin et al (2009) recently conducted a randomized clinical trial of oral analgesics for acute pain in 87 adults aged 50 years or older with herpes zoster. Treatment was begun within 6 days of rash onset and during a period in which the patient experience his or her worst pain within the preceding 24 hours. Patients were initiated on a 7-day course of famciclovir, which was combined with a 28-day course of controlled-release (CR) oxycodone, gabapentin, or placebo. Patients who discontinued participation did so primarily because of constipation (27.6% of patients receiving CR oxycodone and 6.9% of patients receiving placebo). CR oxycodone was more successful in reducing the mean worst pain within the first week than placebo (P =0.01). Gabapentin did not provide significantly greater pain relief than placebo, although the drug did provide modest pain reduction in the first week.5
- A randomized, double-blind, placebo-controlled study of extended-release gabapentin (gabapentin ER) conducted by Irving et al (2009) demonstrated improvement in average daily pain scores in patients with acute herpes zoster. In those taking gabapentin, 25.5%-28.8% reported a pain reduction of 50% or more compared with baseline, whereas 11.8% of patients taking placebo reported the same result.6
- Antiviral therapy
- Multiple agents have demonstrated efficacy in reducing symptoms, lesion number, and duration of cutaneous and ophthalmic zoster episodes in immunocompetent and immunocompromised patients. In the United States, antivirals of choice include acyclovir, valacyclovir, and famciclovir. Side effects and dosing regimens for these drugs are described individually below.
- In general, antiviral therapy has been reported as being most effective if initiated within the first 3 days of symptoms. However, even after 3 days, antiviral therapy has been shown to be efficacious in reducing zoster pain. Thus, antiviral therapy should be considered for acute zoster treatment regimens, regardless of the time of presentation.
- Acyclovir is a guanine derivative that prevents varicella-zoster virus (VZV) replication through inhibition of the viral DNA polymerase. Valacyclovir and famciclovir are prodrugs converted in vivo into acyclovir and penciclovir, respectively. Both of the prodrugs are as effective as acyclovir in resolving pain, and both appear to promote faster healing of cutaneous lesions. Further, both prodrugs have simpler dosing regimens. However, intravenous acyclovir remains the drug of choice for severe or disseminated disease.
- Corticosteroids: The use of steroids in conjunction with an antiviral for acute zoster is controversial. The results of multiple studies have provided no conclusive evidence that steroids shorten the course of acute infection or have any effect on postherpetic neuralgia.7 One study demonstrated that acute neuritis resolved more quickly in patients receiving both corticosteroids and acyclovir compared to patients who received acyclovir alone. Another trial showed a clear improvement in quality of life (eg, decreased analgesic requirements, uninterrupted sleep) among patients using a combined steroid/antiviral regimen compared to control subjects.
Chronic herpes zoster (postherpetic neuralgia)
Primary treatments for postherpetic neuralgia include neuroactive agents such as tricyclic antidepressants, anticonvulsant agents such as gabapentin, and narcotic and nonnarcotic analgesics. No standard treatment plans or protocols exist for treating the pain associated with postherpetic neuralgia. Consultation with pain specialists may be required. Sample medications for treatment of postherpetic neuralgia are described below.
- Prevention of postherpetic neuralgia
- Placebo-controlled trials of various antivirals have shown clear reductions in the pain and duration of postherpetic neuralgia among treated populations. In patients older than 50 years, research has demonstrated a clear improvement in quality of life with treatment in both acute herpes zoster and postherpetic neuralgia. Studies involving the ability of antivirals to prevent postherpetic neuralgia in any age group are inconclusive.
- Aside from antiviral therapy, the other treatment that has shown promise in preventing postherpetic neuralgia in a select population is vaccination. As described above, a large placebo-controlled trial involving a live attenuated VZV vaccine in immunocompetent adults older than 60 years demonstrated a reduction in the incidence of acute herpes zoster by more than 50% and a reduction in the incidence of postherpetic neuralgia of 67% in the treated population. The US Food and Drug Administration (FDA) licensed this vaccine in 2006 for use in adults aged 60 years or older, and the Advisory Committee on Immunization Practices (ACIP) has recommended that nonimmunocompromised, nonpregnant adults aged 60 years or older receive the vaccine, regardless of zoster history.8
Surgical Care
Surgical care is not generally indicated for treatment of herpes zoster. In cases of extreme intractable pain, rhizotomy (surgical separation of pain fibers) may be considered.
Consultations
- Consultation with a dermatologist or infectious disease specialist should be obtained if the diagnosis is in doubt.
- Consultation with an ophthalmologist is suggested for disease affecting the face.
- Consult a pain specialist for severe postherpetic neuralgia.
Diet
No specific dietary changes are recommended.
Activity
- Patients with shingles can perform activities as tolerated.
- During the acute phase, patients should be counseled to avoid direct skin contact with immunocompromised persons, pregnant women, and individuals with no history of chickenpox infection. If the patient is hospitalized, contact isolation measures should be considered.
Medication
As stated above, the goals of drug therapy are to reduce the pain and other symptoms of herpes zoster episodes, and if possible, help to shorten the duration, prevent recurrence, and lower the risk of chronic sequelae.
Antivirals
Reduce pain and time to lesion resolution during the acute phase of shingles and may reduce risk or duration of postherpetic neuralgia.
Acyclovir (Zovirax)
Synthetic purine nucleoside analogue with inhibitory activity against HSV types 1 and 2 and VZV.
Adjust dosage in patients with renal insufficiency.
Adult
800 mg PO 5 times/d for 7-10 d
500 mg/m2 IV or 10 mg/kg IV q8h for 7 d
Pediatric
Immunocompromised children:
250-600 mg/m2 PO 4-5 times/d for 7-10 d
500 mg/m2 IV or 7.5-10.0 mg/kg IV q8h for 7 d
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Exercise caution in renal failure or when using nephrotoxic drugs
Valacyclovir (Valtrex)
Prodrug rapidly converted to the active drug acyclovir. More expensive but has a more convenient dosing regimen than acyclovir.
Adult
1000 mg PO tid for 7 d
Pediatric
Not established
Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and increases CNS toxicity of valacyclovir
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Requires dosage adjustment in renal failure; caution in renal failure and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome; allogenic bone marrow transplant recipients and renal transplant recipients
Famciclovir (Famvir)
After ingestion, the drug is rapidly biotransformed into the active compound penciclovir and phosphorylated by viral thymidine kinase. By competition with deoxyguanosine triphosphate, penciclovir triphosphate inhibits viral polymerase.
Adjust dose in patients with renal insufficiency or hepatic disease.
Adult
500 mg PO tid for 7 d
Pediatric
Not established
Coadministration of probenecid and cimetidine may increase toxicity of penciclovir; coadministration increases bioavailability of digoxin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal insufficiency or hepatic disease; not studied in immunocompromised patients or disseminated disease
Topical anesthetics
Decrease pain associated with postherpetic neuralgia.
Capsaicin (Dolorac, Capsin, Zostrix)
Derived from plants of the Solanaceae family. May render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons.
Adult
Apply to affected area tid/qid
Pediatric
<2 years: Not recommended
>2 years: Administer as in adults
None reported
Documented hypersensitivity; broken or irritated skin
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
For external use only; avoid contact with eyes, mucous membranes, wounds, or damaged skin; do not use tight bandage; discontinue use if condition worsens or symptoms persist for 14-28 d
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli. May help reduce pain, but reports are inconclusive.
Prednisone (Deltasone, Orasone, Sterapred)
Decreases inflammation by suppressing neutrophils and reversing increased capillary permeability. Also suppresses immune system.
Adult
10-50 mg PO qd
Pediatric
Not established
Coadministration with estrogens may decrease prednisone clearance; when used with digoxin, digitalis toxicity secondary to hypokalemia may increase; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; increased susceptibility to infection; peptic ulcer disease; hepatic dysfunction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Tricyclic antidepressants
Have been shown to have a role in the treatment of postherpetic neuralgia.
Amitriptyline (Elavil)
Blocks reuptake of norepinephrine and serotonin. Decreases pain by inhibiting spinal neurons involved in pain perception.
Adult
10-150 mg PO hs; initially administer as smaller divided increments and gradually titrate up to an effective level with a maximum dosage of 150 mg PO qhs
Pediatric
Not currently recommended for children <12 y
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase amitriptyline levels; amitriptyline inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; administration of MAOIs in past 14 d; history of seizures; cardiac arrhythmias; glaucoma; urinary retention
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances, history of hyperthyroidism, and renal or hepatic impairment; avoid using in elderly patients
Vaccines
Elicit active immunization to increase resistance to infection. Vaccines consist of attenuated microorganisms or cellular components, which act as antigens. Administration stimulates antibody production with specific protective properties.
Varicella zoster vaccine (Zostavax)
Lyophilized preparation of Oka/Merck strain of live, attenuated varicella-zoster virus (VZV). Shown to boost immunity against herpes zoster virus (shingles) in older patients. Reduces occurrence of shingles in individuals >60 y by about 50%. For individuals aged 60-69 y, it reduces occurrence by 64%. Also slightly reduces pain compared with no vaccination in those who develop shingles. Indicated for prevention of herpes zoster.
Adult
<60 years: Not established
>60 years: Following reconstitution with entire vial of diluent supplied, use separate sterile needle and syringe to withdraw entire contents of reconstituted vial and administer SC; administer in upper arm
Pediatric
Not indicated
None reported
Documented hypersensitivity to vaccine or components (eg, gelatin, neomycin); history of primary or acquired immunodeficiency states (eg, leukemia, lymphomas, malignant neoplasms affecting bone marrow or lymphatic system, AIDS); immunosuppressive therapy including high-dose corticosteroids; active, untreated tuberculosis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Common adverse effects include erythema, pain, tenderness, itching, and inflammation at injection site; may also cause headache; may cause extensive vaccine-associated rash or disseminated disease in individuals on immunosuppressive therapy (see Contraindications); defer vaccination if fever or acute illness present; do not inject intravascularly; administer within 30 min of reconstitution; not a substitute for varicella virus vaccine (Varivax) for children
More on Herpes Zoster |
| Overview: Herpes Zoster |
| Differential Diagnoses & Workup: Herpes Zoster |
 Treatment & Medication: Herpes Zoster |
| Follow-up: Herpes Zoster |
| Multimedia: Herpes Zoster |
| References |
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References
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Further Reading
Keywords
herpes zoster, shingles, HZ, varicella-zoster virus, VZV, preherpetic neuralgia, postherpetic neuralgia, PHN, varicella, chickenpox, herpes zoster ophthalmicus, HZO, Ramsay-Hunt syndrome, herpes zoster oticus, geniculate neuralgia, herpes zoster auricularis
