eMedicine Specialties > Emergency Medicine > Infectious Diseases
Herpes Zoster Oticus: Treatment & Medication
Updated: Nov 4, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- Adequate analgesia is important for individuals with significant pain from herpes zoster.
- Nausea and vomiting may require ED treatment.
- Complications, such as corneal irritation or secondary bacterial infection of the vesicles, should be managed with routine therapies.
- Involvement of more than one dermatome is atypical and should prompt the search for possible immunoincompetence.
Consultations
- Consider an ophthalmologic consultation if corneal involvement with vesicles is noted.
- Consider a neurologic consultation if the etiology of the facial paralysis is unclear.
Medication
Until recently, therapy for herpes zoster (HZ) oticus has been generally supportive, including warm compresses, narcotic analgesics, and antibiotics for a secondary bacterial infection. However, antiviral agents clearly play a role in limiting the severity and duration of symptoms if given early in the course of the illness. Early administration (<72 h) of acyclovir showed an increased rate of facial nerve function recovery and prevented further nerve degeneration. Furthermore, use of antivirals has shown to decrease incidence and severity of postherpetic neuralgia. Evidence is accumulating that VZV may be responsible for many cases of Bell palsy that go unrecognized because of a lack of cutaneous findings (zoster sine herpete). Accordingly, the clinician should entertain more liberal use of antivirals such as acyclovir, valacyclovir, and famciclovir. Studies have shown no difference between oral and IV acyclovir in immunocompetent patients with facial nerve paralysis.1
Systemic corticosteroids are used to relieve acute pain, decrease vertigo, and limit the occurrence of postherpetic neuralgia. Treatment with acyclovir plus prednisone has more effective return to facial nerve function and prevention of nerve degeneration than treatment with prednisone alone. Furthermore, patients treated with acyclovir plus prednisone had better outcomes (time to healing of rash, time to cessation of acute neuritis, time to return to usual activity and sleep, and time to cessation of analgesics) than those treated with either prednisone or acyclovir alone.2 No evidence indicates that use of corticosteroids prevents development of post-herpetic neuralgia.3,4 Furthermore, evidence proving benefit attributed specifically to steroids is still limited, with a recent review showing no randomized controlled trials supporting use of steroids as an adjuvant to antiviral medications in the treatment of Ramsay Hunt Syndrome.5
For treatment of herpes zoster in patients with HIV, inpatient parenteral regimens should be reserved for those with severe immunosuppression, trigeminal nerve involvement, ocular lesions, or multidermatomal involvement. For acyclovir-resistant VZV, IV foscarnet is an appropriate alternative therapy (famciclovir and valacyclovir are not effective against acyclovir-resistant VZV). For outpatient regimens, famciclovir or valacyclovir for 7-10 days is recommended (both have the advantage of easier dosing regimens). Routine use of steroids is discouraged secondary to its immunosuppressive effects.6
Treatment of pregnant women with VZV is the same as for nonpregnant women, and it is the same for both HIV-seronegative and seropositive patients.
When secondary impetigo is present, a suitable antistaphylococcal antibiotic should be prescribed.
Cyclic antidepressants, anticonvulsants, opioids, and topical analgesics are sometimes used in the treatment of postherpetic neuralgia.7 These agents are more appropriately started by a pain management specialist in an outpatient setting.
Prevention of herpes zoster by vaccination is recommended for all persons aged older than 60 years, even if they have had chickenpox or zoster in the past. This age group suffers significant morbidity from zoster and may, therefore, benefit from the vaccine. Contraindications to vaccine administration include age younger than 60 years, current use of antivirals, pregnancy, and certain immunosuppressive conditions.8
Antivirals
These agents prevent the replication of viral particles. Antiviral medications can be directed against VZV. Acyclovir is the prototypical antiherpetic. Newer agents, famciclovir and valacyclovir, may be more effective and have more convenient dosing. All of these agents have reduced effectiveness if administered more than 72 h after development of the rash.
Acyclovir (Zovirax)
Oral acyclovir aborts symptom recurrences if treatment initiated immediately upon symptom onset (within 48 h of rash). Treated patients have less pain and faster resolution of cutaneous lesions.
Adult
800 mg PO 5 times/d for 7-10 d
Severe infections: 10-12 mg/kg IV q8h for 7-14 d
Pediatric
Not established
Suggested dose: 10-20 mg/kg/dose (up to 800 mg) PO qid for 5 d
Probenecid or zidovudine prolongs half-life and increases 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
Caution in renal failure or when using nephrotoxic drugs
Famciclovir (Famvir)
Prodrug that, when biotransformed into active metabolite penciclovir, may inhibit viral DNA synthesis/replication.
Adult
500 mg PO q8h for 7 d
Pediatric
Not established
Probenecid or cimetidine may increase toxicity; 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
Valacyclovir (Valtrex)
Prodrug that rapidly converts to acyclovir before exerting its antiviral activity. Valacyclovir is more expensive but has more convenient dosing regimen than acyclovir.
Adult
1000 mg PO tid for 7 d
Pediatric
Not established
Probenecid, zidovudine, or cimetidine prolongs half-life and increases 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
Caution in renal failure and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome
Corticosteroids
These agents may help to relieve acute pain, decrease vertigo, and limit occurrence of postherpetic neuralgia.
Prednisone (Deltasone, Orasone, Sterapred)
Treats inflammatory and allergic reactions. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
30 mg PO bid for days 1-7; 15 mg PO bid for days 8-14; 7.5 mg bid for days 15-21
Pediatric
4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; not to exceed 60 mg/d; taper over 2 wk as symptoms resolve
Estrogens may decrease clearance; use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; fungal or tubercular skin infections
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
Analgesics
With complaints of severe pain at any point at or beyond the appearance of crusted vesicles, assume that postherpetic neuralgia has developed. This can be extremely debilitating and requires aggressive management. Use narcotic analgesics liberally. NSAIDs and steroids have limited proven benefit in the treatment of postherpetic neuralgia.
Capsaicin cream applied topically to the affected areas generally is associated with dramatic relief. Capsaicin works by depleting pain fibers of substance P, thereby inhibiting propagation of pain impulses. It must be applied regularly qid and patients should be forewarned that the first application or two will be associated with a mild burning or stinging.
Oxycodone and aspirin (Percodan)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab/cap PO q4-6h prn pain
Pediatric
0.05-0.15 mg/kg/d oxycodone PO q4-6h prn; not to exceed 5 mg/dose oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity; may potentiate anticoagulant effects of warfarin
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma
Because of association with Reye syndrome, do not use in children (<16 y) who have flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly persons; caution in renal or liver impairment, peptic ulcer disease, and erosive gastritis
Oxycodone and acetaminophen (Percocet, Tylox)
Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24 h of acetaminophen; higher doses may cause liver toxicity
Hydrocodone bitartrate and acetaminophen (Vicodin, Lorcet)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab/cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity
Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Hydrocodone and aspirin (Lortab)
Drug combination indicated for relief of moderately severe to severe pain.
Adult
1-2 tab PO q4-6h prn pain
Pediatric
Not established
Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity; may potentiate anticoagulant effects of warfarin
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in impaired renal function, peptic ulcer disease, and erosive gastritis; duration of action may increase in elderly persons
Hydrocodone and ibuprofen (Vicoprofen)
Drug combination indicated for short-term (<10 d) relief of moderately severe to severe acute pain.
Adult
1-2 tab PO q4-6h prn pain; not to exceed 5/tab d
Pediatric
Not established
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
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
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in impaired renal function, peptic ulcer disease, impaired thyroid function, asthma, hypertension, edema, heart failure, increased intracranial pressure, and erosive gastritis; duration of action may increase in the elderly
Capsaicin (Dolorac, Capsin, Zostrix)
Natural chemical derived from plants of Solanaceae family. May render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons. Substance P may play role in pain transmission from periphery to CNS.
Adult
Apply 1% cream topically to affected area tid/qid for 3-4 d (initial use associated with stinging); not to exceed 4 applications/d
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; broken or irritated skin
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
For external use only; avoid contact with eyes; do not use tight bandage; discontinue use if condition worsens or symptoms persist for 14-28 d
Ocular lubricants
These drugs promote hydration of cornea and conjunctivae. If eyelid paralysis is present, corneal irritation may result due to inadequate maintenance of the protective tear film. Use lubricating eyedrops as needed.
Artificial tears (Tear Gard, Refresh, Celluvisc)
Drug contains equivalent of 0.9% NaCl to maintain ocular tonicity.
Adult
Instill prn
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Blurred vision common following administration; caution when patient is wearing glasses
Antibiotics
These agents are for treatment of secondary bacterial infection in HZ oticus. These drugs cover for gram-positive skin flora.
Amoxicillin-clavulanate (Augmentin)
Drug combination extends antibiotic spectrum of this penicillin to include bacteria normally resistant to beta-lactam antibiotics.
Indicated for skin and skin-structure infections caused by beta-lactamase–producing strains of Staphylococcus aureus.
Administer treatment for minimum of 7 d.
Adult
500 mg PO tid for 7 d
Pediatric
40-50 mg/kg based on amoxicillin component PO divided tid for 7 d
Warfarin or heparin increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Give for minimum of 10 d to eliminate organism and prevent sequelae (endocarditis, rheumatic fever); following treatment, perform cultures to confirm eradication of staphylococci
Azithromycin (Zithromax)
DOC for penicillin-allergic patients. Used to treat mild to moderately severe infections caused by susceptible strains of microorganisms.
Adult
500 mg PO on day 1, then 250 mg PO qd for 4 d
Pediatric
10 mg/kg PO on day 1, then 5 mg/kg PO qd for 4 d
May increase toxicity of theophylline, warfarin, and digoxin; aluminum and/or magnesium antacids reduce effects; cyclosporine may cause nephrotoxicity and neurotoxicity
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged use; may increase hepatic enzymes and risk of cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
More on Herpes Zoster Oticus |
| Overview: Herpes Zoster Oticus |
| Differential Diagnoses & Workup: Herpes Zoster Oticus |
 Treatment & Medication: Herpes Zoster Oticus |
| Follow-up: Herpes Zoster Oticus |
| References |
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References
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Murakami S, Honda N, Mizobuchi M. Rapid diagnosis of varicella zoster virus infection in acute facial palsy. Neurology. Oct 1998;51(4):1202-5. [Medline].
Whitley RJ, Weiss H, Gnann JW. Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Ann Intern Med. Sep 1 1996;125(5):376-83. [Medline].
Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med. Mar 31 1994;330(13):896-900. [Medline].
Uscategui T, Doree C, Chamberlain IJ, Burton MJ. Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database Syst Rev. Jul 16 2008;CD006852. [Medline].
Benson CA, Kaplan JE, Masur H. Treating opportunistic infections among HIV-exposed and infected children: recommendations from CDC, the National Institutes of Health, and the Infectious Diseases Society of America. MMWR Recomm Rep. Dec 17 2004;53(RR-15):1-112. [Medline].
Pavan-Langston D. Herpes zoster antivirals and pain management. Ophthalmology. Feb 2008;115(2 Suppl):S13-20. [Medline].
Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Jun 6 2008;57:1-30; quiz CE2-4. [Medline].
Adour KK. Otological complications of herpes zoster. Ann Neurol. 1994;35 Suppl:S62-4. [Medline].
Bauer CA, Coker NJ. Update on facial nerve disorders. Otolaryngol Clin North Am. Jun 1996;29(3):445-54. [Medline].
Murakami S, Hato N, Horiuchi J. Treatment of Ramsay Hunt syndrome with acyclovir-prednisone: significance of early diagnosis and treatment. Ann Neurol. Mar 1997;41(3):353-7. [Medline].
Sweeney CJ, Gilden DH. Ramsay Hunt syndrome. J Neurol Neurosurg Psychiatry. Aug 2001;71(2):149-54. [Medline].
Further Reading
Keywords
herpes zoster oticus, HZ oticus, viral infection of the ear, Ramsay Hunt syndrome, facial paralysis, varicella-zoster virus, VZV, reactivation of varicella-zoster virus, reactivation of VZV, postherpetic neuralgia, otalgia, hearing loss, vertigo
