eMedicine Specialties > Emergency Medicine > Infectious Diseases
Herpes Zoster Ophthalmicus: Treatment & Medication
Updated: Sep 18, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
Emergency department care of herpes zoster ophthalmicus (HZO) includes local wound care, adequate analgesia, starting antiviral agents, and antibiotics for secondary bacterial infection. When the blinking reflex and eyelid function are compromised, an eye lubricant is needed to prevent corneal desiccation injury.
- Oral acyclovir has been shown to shorten the duration of signs and symptoms, as well as to reduce the incidence and severity of HZO complications. While it has effect in reducing the pain during the acute phase, it has no demonstrated effect on reducing the incidence or severity of postherpetic neuralgia.6 Acyclovir appears to benefit patients the most whose therapy is initiated within 72 hours of onset of the skin lesions, with higher complication rates occurring among patients whose treatment was delayed.6,7
- Both famciclovir and valacyclovir (500 mg tid) have been shown to be as effective as acyclovir (800 mg 5 times a day) in the treatment of herpes zoster and reduction in complications.8,9 These medications have simpler dosing regimens than acyclovir, which may increase patient compliance.
- The effectiveness of therapy started more than 72 hours after symptom onset is not clearly established, yet there is no evidence against the benefits of antiviral agents even after 72 hours. Theoretically, the ongoing viral replication can be deterred at any time if the rash continues, especially if new lesions appear.
- The standard duration of antiviral therapy for HZ is 7-10 days. Nevertheless, the VZV DNA had been shown to persist in the cornea for up to 30 days. This is especially true in elderly individuals. This information implies that the antiviral regimens may have to be continued, particularly for immunocompromised and elderly patients, although no clinical trials have proven their efficacy in this particular patient population. More serious complications, such as retinal involvement, may require days of intravenous therapy and months of oral antiviral therapy.
- The use of oral corticosteroids has been shown to reduce the duration of pain during the acute phase of the disease and to increase the rate of cutaneous healing; however, it has not been shown to decrease the incidence of postherpetic neuralgia.10,11 While steroids do improve quality of life, they are not appropriate for all patients and should be reserved for those patients who are relatively healthy and in whom there is no contraindication.
- Steroid eye drops may be beneficial for HZO, yet it is only helpful in certain ocular diseases (see below) and can exacerbate others (ie, epithelial keratitis). Therefore, ophthalmologic consultation is mandatory prior to initiating ocular steroid therapy.
- If a patient complains of severe pain at any point at or beyond the appearance of crusted vesicles, the clinician should strongly suspect that postherpetic neuralgia has developed. Treatment of postherpetic neuralgia is complex. A multifaceted, patient-specific approach is important. Clinical trials have shown that opioids, tricyclic antidepressants, and anticonvulsants (carbamazepine, gabapentin) may reduce the severity or duration of postherpetic neuralgia, either as single agents or in combination. Topical application of lidocaine patches or capsaicin cream may provide relief for some patients. Consultation with a pain therapist may be required.
- Anesthesia-based interventions such as local anesthetic blocking of sympathetic nerves or stellate ganglion blockade may produce transient relief, yet their effectiveness in reducing the protracted pain is still in question. Transcutaneous electric nerve stimulation, and, if necessary, neurosurgery (eg, thermocoagulation of substantia gelatinosa Rolandi) has been found to be helpful in exceptional cases.
- Each specific ophthalmic complication due to HZO has specific treatment modalities, and these should be initiated in consultation with an ophthalmologist. The following is the recommended treatment as shown in Shaikh and Ta's review of HZO12 :
- Blepharitis/conjunctivitis - Palliative, with cool compresses and topical lubrication; topical antibiotics for secondary infections
- Stromal keratitis - Topical steroids
- Neurotrophic keratitis - Topical lubrication; topical antibiotics for secondary infections; tissue adhesives and protective contact lenses to prevent corneal perforation
- Uveitis - Topical steroids; oral steroids; oral acyclovir; cycloplegics
- Scleritis/episcleritis - Topical nonsteroidal anti-inflammatory agents and/or steroids
- Acute retinal necrosis/progressive outer retinal necrosis - Intravenous acyclovir (1500 mg per m2 per day divided into 3 doses) for 7-10 days, followed by oral acyclovir (800 mg orally 5 times daily) for 14 weeks; laser/surgical intervention
Consultations
- An ophthalmologic consultation is crucial if the diagnosis of HZO is a possibility.
- An anesthesia consultation may be helpful in treating patients with refractory pain.
- Occasionally, a surgical consultation is required for debridement of involved forehead skin epithelium.
Medication
Antiviral agents, acyclovir, valacyclovir, and famciclovir, are approved in the United States for the management of HZ. Because of their superior pharmacokinetic profiles and simpler dosing regimens, valacyclovir and famciclovir may be preferred over acyclovir.
In an attempt to make the dosing regimen easier to ensure compliance, some researchers studied famciclovir to see if less frequent dosing would be as effective as current dosing recommendations.13 While the once-daily regimen of famciclovir 750 mg reduced the cutaneous symptoms and pain as effectively as the standard regimen, the effect on postherpetic neuralgia and ocular disease was not discussed.
The use of corticosteroids in HZO is only recommended in combination with antiviral agents. Corticosteroid therapy should not be used in patients at risk for corticosteroid-induced toxicity (eg, patients with diabetes mellitus or gastritis). Topical steroids alone do not reactivate the virus but may exacerbate spontaneous recurrences.
Antiviral agents
These agents interfere with DNA synthesis and inhibit viral replication. The current recommendation is to begin the antiviral therapy within 72 hours of symptom onset. An adjustment in the dose of the chosen antiviral agent is required in patients with renal insufficiency. Antiviral therapy reduces the frequency of late ocular complications from about 50% in untreated patients to about 20-30% in treated patients.
Acyclovir (Zovirax)
Reduces duration of cutaneous lesions and herpetic pain. Indicated for patients presenting within 48 h of rash onset.
Adult
800 mg PO q4h or 5 times/d for 7-10 d
Renal dose if creatinine clearance (mL/min/1.73 m2) is:
>25, No adjustment necessary
10-25: 800 mg q8h
0-10: 800 mg q12h
Pediatric
Not established; suggested dose is 10-20 mg/kg (up to 800 mg) PO q4h or 5 times/d for 5 d
Antifungals and interferons may have synergistic or additive effect; probenecid prolongs half-life (drugs eliminated by renal excretion); zidovudine may increase CNS toxicity
Documented hypersensitivity
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
Use renal dose in renal failure or when using with nephrotoxic drugs
Famciclovir (Famvir)
Prodrug of penciclovir, reduces duration of viral shedding, thereby limiting duration of new lesion formation, accelerating healing.
Adult
500 mg PO 3 times/d for 7 d
Pediatric
Not established
Probenecid or other drugs eliminated by renal excretion prolongs half-life and may increase toxicity; drugs metabolized by aldehyde oxidase
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 with nephrotoxic drugs
Valacyclovir (Valtrex)
Prodrug of acyclovir, produces serum acyclovir levels that are 3-5 times as high as those achieved with oral acyclovir therapy.
Adult
1000 mg PO 3 times/d for 7 d
Pediatric
Not established
Probenecid, cimetidine prolongs half-life (increases peak plasma concentrations)
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 with nephrotoxic drugs
Analgesics
Acute herpetic pain control and postherpetic neuralgia pose quite a challenge for physicians. Following are some options for pharmacological analgesia.
Oxycodone (OxyContin, Roxicodone, OxyIR)
Indicated for relief of moderately severe to severe pain.
Adult
5 mg PO q6h for total dose of 80 mg/d (or higher in tolerant individuals)
Pediatric
0.05-0.15 mg/kg/dose PO q6h, not to exceed 5 mg/dose
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause more sedation and respiratory depression in acute alcoholism, adrenocortical insufficiency (eg, Addison disease), debilitated patients, hypothyroidism, severe impairment of hepatic, pulmonary or renal function, and toxic psychosis
Topical analgesics
These agents are indicated for application to normal, intact skin, to provide topical anesthesia.
Capsaicin (Dolorac, Zostrix)
Natural substance derived from plants of Solanaceae family. Useful for acute pain relief; may titrate up to higher concentration (1%).
Adult
Apply topically 0.025-0.075% cream tid/qid to affected area
Pediatric
Apply 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
Discontinue use if condition worsens or if symptoms persist for 14-28 d
Lidocaine 5% Patch (Lidoderm)
Useful as topical for pain relief, especially indicated for postherpetic neuralgia
Adult
Up to 3 patches at a time to painful area (maximum of 12 h)
Pediatric
Not established
With Class I antiarrhythmic drugs (eg, tocainide, mexiletine) toxic effects can be synergistic or additive; when used concomitantly with other products containing local anesthetic agents, the amount absorbed from all formulations must be considered
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Localized skin irritation; systemic toxicity from cutaneous absorption of lidocaine very rare
Tricyclic antidepressants
These agents are used for pain relief in postherpetic neuralgia.
Nortriptyline (Pamelor)
Useful as analgesic for certain chronic and neuropathic pain syndromes.
Adult
10-25 mg PO at bedtime; begin at low dose and titrate upwards (to 75-150 mg/d)
Pediatric
Not recommended for children
Reserpine, alcohol may have additive or synergistic effects; increased side effects such as sedation and confusion with other anticholinergic drugs and sympathomimetic drugs; cimetidine increases the plasma concentrations; CYP2D6 enzyme system inhibitors thus may increase levels of other drugs metabolized by this system
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Use of MAOIs in past 14 d; recent MI; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention
Anticonvulsants
Only one drug in this class, gabapentin, has been proven to be useful for the management of postherpetic neuralgia in adults.
Gabapentin (Neurontin)
Only anticonvulsant to be evaluated for management of post-herpetic neuralgia; proven to be effective in randomized placebo-controlled trial.
Adult
300 mg PO qd (single dose); titration of dose as necessary over 4 wk period, to total daily dose of 3600 mg (divided into 2-3 doses as dosage increases)
Pediatric
Not established
Not appreciably metabolized nor does it interfere with the metabolism of commonly coadministered antiepileptic drugs; absorption and concentration may increase with cimetidine, morphine, and naproxen; decreases concentration of hydrocodone; Maalox may decrease gabapentin's bioavailability
Documented hypersensitivity
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
Caution in severe renal disease
More on Herpes Zoster Ophthalmicus |
| Overview: Herpes Zoster Ophthalmicus |
| Differential Diagnoses & Workup: Herpes Zoster Ophthalmicus |
 Treatment & Medication: Herpes Zoster Ophthalmicus |
| Follow-up: Herpes Zoster Ophthalmicus |
| References |
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References
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Further Reading
Keywords
herpes zoster ophthalmicus, eye infection, herpes zoster, varicella-zoster virus, varicella zoster virus, VZV, HZO, herpes virus, chickenpox, shingles, human herpesvirus type 3
