eMedicine Specialties > Infectious Diseases > Viral Infections
Varicella-Zoster Virus: Treatment & Medication
Updated: Nov 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Treatment options are based on the patient's age, immune state, duration of symptoms, and presentation.
- Several studies indicate that antiviral medications decrease the duration of symptoms and the likelihood of postherpetic neuralgia, especially when initiated within 2 days of the onset of rash. In typical cases that involve individuals who are otherwise healthy, oral acyclovir may be prescribed. An important study by Kubeyinje (1997) suggested that the use of acyclovir in healthy young adults with zoster is not clearly justified, especially in situations of limited economic resources.2
- Acyclovir has 2 limitations—bioavailability and the existence of some resistant strains of varicella-zoster virus (VZV).
- Other medications, including valacyclovir, penciclovir, and famciclovir, are also available. They may have an increasing role in the treatment of typical zoster. Studies suggest that, when compared with oral acyclovir, the new medications may decrease the duration of the patient's pain.
- Dworkin et al (2009) conducted a randomized, placebo-controlled trial of oral oxycodone and oral gabapentin as potential treatments for acute pain in patients with herpes zoster. They found that controlled-release oxycodone was superior to placebo in the early period of pain (1-14 d). Gabapentin was not shown to yield a significantly greater relief of pain than placebo, although it conferred modest pain relief during the first week.3
Surgical Care
Surgical care may be required for complications of zoster, such as necrotizing fasciitis.
Consultations
- Consultation with a neurologist is indicated in cases of myelitis or encephalitis.
- Consultation with an infectious disease specialist may be helpful if bacterial superinfection or viral resistance to acyclovir is evident.
- Consultation with an ophthalmologist is indicated upon optic involvement.
- Consultation with a dermatologist may be helpful when the rash is atypical.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Current research is considering whether the varicella vaccine may also prove efficacious as treatment for active varicella-zoster virus (VZV) infection.
Antiviral agents
Three medications may help reduce pain and symptoms and the incidence of postherpetic neuralgia. All need to be used with caution in patients with renal compromise. Hemolytic uremic syndrome is rare but has been reported. All 3 agents may be used for 7-10 d, depending on response. Only acyclovir is available in an intravenous form.
Acyclovir (Zovirax)
Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks.
Adult
800 mg PO 5 times/d for 7-10 d; difficult to verify patient compliance because of dosage frequency
10 mg/kg IV q8h for complications or atypical presentations or in cases of immunosuppression
Pediatric
Not established; IV dose is based on body weight
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
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 7-10 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
Caution in renal failure and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome
Famciclovir (Famvir)
Prodrug that, when biotransformed into active metabolite penciclovir, may inhibit viral DNA synthesis/replication.
Adult
500 mg PO tid for 7-10 d
Pediatric
Not established
Coadministration of probenecid or cimetidine may increase toxicity; 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
Caution in renal failure or coadministration of nephrotoxic drugs
Vaccine, Live Virus
These agents are used to induce active immunity.
Varicella virus vaccine (Varivax)
A live attenuated varicella virus prepared from the Oka/Merck strain. It is propagated in human diploid cell cultures (MRC-5). Each 0.5-mL dose (when reconstituted) contains 1350 PFU of varicella, sucrose, and gelatin; residual components of MRC-5 DNA and protein; and trace quantities of neomycin and fetal bovine serum. Indicated for vaccination against varicella in individuals >1 y.
Adult
0.5 mL SC initially, follow in 4-8 wk with second 0.5-mL dose
Pediatric
1-12 years: 0.5 mL SC once
>13 years: Administer as in adults
Avoid salicylates (aspirin) for 6 wk following vaccination (Reye syndrome has been reported following use of aspirin during natural varicella infection); defer vaccination for >5 mo following administration of blood, plasma, or immune globulin or varicella zoster immune globulin (VZIG) because antivaricella antibodies in these preparations may decrease vaccine effect
Documented hypersensitivity; primary or acquired immunodeficiency; patients receiving immunosuppressive therapy (may result in a more extensive vaccine-associated rash or disseminated disease); 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
Because the vaccine is live, recipients may transmit the vaccine virus to close contacts (avoid close contact with susceptible high-risk people [ie, newborns, pregnant women, immunocompromised patients])
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 is present; do not inject intravascularly; administer within 30 min of reconstitution; not a substitute for varicella virus vaccine (Varivax) for children
Topical Analgesics
Topical analgesics that contain capsaicin are effective in decreasing neuropathic pain caused by postherpetic neuralgia.
Capsaicin transdermal patch (Qutenza)
Transient receptor potential vanilloid-1 (TRPV1) agonist indicated for neuropathic pain associated with postherpetic neuralgia. TRPV1 is an ion channel–receptor complex expressed on nociceptive skin nerve fibers. Topical capsaicin causes initial TRPV1 stimulation that may cause pain, followed by pain relief by reduction in TRPV1-expressing nociceptive nerve endings. Neuropathic pain may gradually recur over several months (thought to be caused by TRPV1 nerve fiber reinnervation of treated area).
Adult
Only physicians or healthcare professionals are to administer patch
Application preparation:
Use nitrile gloves during application process; latex gloves do not provide adequate protection
Clip hair if necessary (do not shave)
Gently wash treatment area with mild soap and water; dry thoroughly
Patch may be cut to match size and shape of treatment area (cut to size/shape before removing protective release liner)
Pretreat area with topical anesthetic to reduce pain associated with patch application
Recommended dose:
Each patch contains 8% capsaicin (640 mcg/cm2; 179 mg/patch)
Single, 60-min application of up to 4 patches to dry, intact (unbroken) skin
May repeat no more frequently than q3mo
Patch removal:
Gently remove and slowly roll patch inward (avoid aerosolization)
Cleanse skin by generously applying cleansing gel (supplied with patch) to affected area; leave on for at least 1 min, then remove with dry wipe and gently wash area with mild soap and water
Pediatric
<18 years: Not established
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Monitor for at least 1 h after patch application because of risk for increased blood pressure; may cause transient increased pain, erythema, swelling, pruritus, and papules at application site; do not apply to face or scalp to avoid exposure to eyes or mucous membranes; remove patch gently to avoid aerosolization (airborne capsaicin can result in coughing or sneezing); apply patch within 2 h of opening package; treated area may be sensitive to heat for several days (eg, hot water, direct sunlight, vigorous exercise)
More on Varicella-Zoster Virus |
| Overview: Varicella-Zoster Virus |
| Differential Diagnoses & Workup: Varicella-Zoster Virus |
 Treatment & Medication: Varicella-Zoster Virus |
| Follow-up: Varicella-Zoster Virus |
| Multimedia: Varicella-Zoster Virus |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
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Kubeyinje EP. Cost-benefit of oral acyclovir in the treatment of herpes zoster. Int J Dermatol. Jun 1997;36(6):457-9. [Medline].
[Best Evidence] 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. Apr 2009;142(3):209-17. [Medline].
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Further Reading
Clinical trials
A Study of FV-100 Versus Valacyclovir in Patients With Herpes Zoster
Live Zoster Vaccine in HIV-Infected Adults on Antiretroviral Therapy
Safety & Immunogenicity of GlaxoSmithKline Biologicals' Herpes Zoster Vaccine 1437173A
Immune Response to Varicella-Zoster Vaccination and Infection
Keywords
varicella-zoster virus, VZV, VZV infection, varicella-zoster virus infection, herpes zoster, shingles, zoster, postherpetic neuralgia, PHN, disseminated VZV infection, VZV encephalitis, varicella-zoster virus encephalitis, chickenpox, disseminated varicella-zoster virus infection, keratitis, herpes ophthalmicus, myelitis, impetiginization, zoster multiplex, zoster duplex unilateralis, zoster sine herpete, Ramsay-Hunt syndrome
