eMedicine Specialties > Emergency Medicine > Infectious Diseases
Herpes Zoster: Treatment & Medication
Updated: Jun 1, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
Symptomatic treatment
- Patients with herpes zoster usually experience pain. Antiviral and steroid therapy provides relatively minor relief of pain, and analgesics are often needed.
- Initial therapy may include nonsteroidal anti-inflammatory drugs (NSAIDs).
- In many cases, narcotic analgesia is necessary.
- A randomized clinical trial of oral analgesics for acute pain in patients with herpes zoster was conducted (n-87; age 50 years or older). Treatment was begun within 6 days of rash onset and with worst pain within 24 hours. Patients were initiated on a 7-day course of famciclovir with controlled-release (CR) oxycodone, gabapentin, or placebo for 28 days. Discontinuing participation, primarily associated with constipation, occurred most frequently in patients randomized to CR-oxycodone (27.6%) compared with placebo (6.9%). Mean worst pain was reduced the first week with CR-oxycodone compared with placebo (p=0.01). Gabapentin did not provide significantly greater pain relief than placebo, although the first week provided a modest reduction of pain.2
- A randomized, double-blind, placebo-controlled study of extended-release gabapentin (gabapentin ER) demonstrated improvement in average daily pain score in patients with acute herpes zoster. In those taking gabapentin, a reduction of pain of 50% or greater from baseline was reported by 25.5-28.8% compared with 11.8% of patients taking placebo.3
- Wet to dry dressings with tap water or 5% aluminum acetate (Burow solution). Apply to the affected skin for 30-60 minutes 4-6 times per day.
- Bland lotions (ie, Calamine) may help relieve discomfort.
Antiviral therapy for uncomplicated herpes zoster
The goals of antiviral therapy are to decrease pain, to promote healing of skin lesions, and to prevent or reduce the severity of postherpetic neuralgia. Acyclovir and the newer antivirals valacyclovir and famciclovir have been shown to be effective if given within 48-72 hours of the appearance of the rash. The newer agents have better bioavailability and do not need to be given as frequently. Outcomes studied have included time to crusting of skin lesions, duration and severity of acute pain, and duration and incidence of postherpetic neuralgia.4
Acyclovir has been the most studied and widely recommended, but in a blinded, randomized comparison trial, valacyclovir was shown to be superior to acyclovir.5,6 The trial included more than 1100 patients with uncomplicated zoster who were 50 years or older. Adverse effects were similar in both groups. Outcomes evaluated included resolution of acute pain and the duration of postherpetic neuralgia.
The duration of antiviral treatment in studies has varied from 7-21 days. Based on current literature, for immunocompetent patients, acyclovir for 7-10 days or a 7-day course of the newer agents is appropriate. Longer courses may be needed in immunocompromised patients.
Combined antiviral and corticosteroid therapy for uncomplicated herpes zoster
The addition of corticosteroids has been evaluated in patients treated with acyclovir. The benefit of steroids included accelerated healing of lesions and more rapid resolution of acute pain.7 Though statistically significant, the benefits were small. There was no effect on the development or duration of postherpetic neuralgia.
Steroids have not been studied with valacyclovir of famciclovir, so the benefit is unknown. The addition of steroids should be considered only in patients with severe symptoms. Steroids should not be given alone (without antiviral therapy) due to concern about promotion of viral replication. The effect of steroids on the incidence of secondary skin infection is unknown. Some authors have suggested that they may increase the risk. Prednisone, 40-60 mg/day, is a reasonable choice if steroids are used. The optimal duration of steroid therapy is not known. If prescribed, it seems reasonable for steroids to be used concurrently with antiviral therapy. The duration of steroid use should not extend beyond the period of antiviral therapy.
Treatment of complicated herpes zoster
Patients who are immunosuppressed are at risk for extensive skin involvement or disseminated disease. Although strong evidence is lacking, the following are highlights of some of the current recommendations for treating zoster in these patients.
- Treat all immunosuppressed patients with antivirals, even when the onset of symptoms is more than 72 hours.
- Valacyclovir should be used if oral therapy is selected.
- Consider treatment with intravenous acyclovir for the following patients:
- Transplant patients soon after transplantation or when being treated for rejection
- Patients with advanced HIV
- Patients with widespread skin involvement or visceral disease
Treatment of herpes zoster ophthalmicus
Two trials comparing oral acyclovir to famciclovir or valacyclovir in patients with ophthalmic zoster showed comparable outcomes with any of the regimens.8 Patients with diagnosed or suspected ophthalmic zoster should receive antivirals and be referred to an ophthalmologist.
Post exposure prophylaxis
Varicella-zoster immune globulin (VZIG) prevents or modifies clinical illness in susceptible, persons who are exposed to varicella or zoster. It should be reserved for patients at risk for complications such as those who are immunocompromised, pregnant, and for neonates.9
Consultations
- Consultation is not generally needed in cases of uncomplicated zoster.
- Consultation with an infectious disease or other appropriate specialist should be considered in cases of disseminated zoster, zoster with visceral involvement, or zoster in an immunocompromised patient.
- Patients in whom ophthalmic zoster is present or cannot be confidently ruled out should usually be referred to an ophthalmologist.
Medication
Goals of therapy in herpes zoster infection are to (1) shorten the clinical course, (2) provide analgesia, (3) prevent complications, and (4) decrease incidence of postherpetic neuralgia. Meta-analyses and randomized controlled trials suggest that the oral antiviral agents acyclovir, famciclovir, and valacyclovir started within 72 hours of the onset of rash reduce both the severity and the duration of acute pain, as well as the incidence of postherpetic neuralgia.
Antiviral agents
Acyclovir antivirals may decrease incidence of postherpetic neuralgia. Famciclovir and valacyclovir (2 antiviral agents with properties similar to those of acyclovir) offer better dosing regimens than acyclovir and yet are less studied.
Acyclovir (Zovirax)
Reduces duration of symptomatic lesions. Indicated for patients who present within 48 h of onset of rash. Treated patients experience less pain and faster resolution of cutaneous lesions.
Adult
800 mg PO q4h (5 times/d) for 7-10 d; alternatively, 10 mg/kg/dose or 500 mg/m2/dose IV q8h
Pediatric
250-600 mg/m2/dose PO 4-5 times/d for 7-10 d; alternatively, 10 mg/kg/dose or 500 mg/m2/dose IV q8h
Probenecid or zidovudine prolongs half-life and increases CNS toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution with renal failure or coadministration of other 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 rapidly converted to acyclovir before exerting its antiviral activity. More expensive but more convenient dosing regimen than acyclovir.
Adult
1000 mg PO q8h for 7 d
Pediatric
Not established
Probenecid, zidovudine, or cimetidine prolongs half-life and increases CNS toxicity
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
Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli. The addition of oral prednisolone to acyclovir treatment has been shown to reduce pain, to speed healing of lesions, and to enable a more rapid return to daily activities.
Prednisone (Deltasone, Orasone, Meticorten)
The addition of a corticosteroid to acyclovir resulted in decreased acute pain but no decrease in long-term pain. One study also demonstrated more rapid initial healing of rash, although time to complete rash resolution was unchanged.
Adult
60 mg/d PO tapered over 3 wk
Pediatric
0.05-2 mg/kg PO divided bid/qid; taper over 2 wk
Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, tubercular skin, and connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI bleeding or ulceration
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
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and enable physical therapy regimens. Most analgesics have sedating properties that are beneficial for patients who have skin lesions.
Acetaminophen (Tylenol, Aspirin-Free Anacin)
DOC for treatment of pain in patients who (1) have documented hypersensitivity to aspirin or NSAIDs, (2) have upper GI disease, or (3) are taking oral anticoagulants. Reduces fever by direct action on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.
Adult
325-650 mg PO q6h, or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 650 mg q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-P deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Ibuprofen (Motrin, Advil, Nuprin)
DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, in turn, inhibiting prostaglandin synthesis. One of few NSAIDs indicated for reduction of fever.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<16 years: Not recommended because of association with Reye syndrome
>16 years: Administer as in adults
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; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Vaccines
These agents 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 in patients >60y who have no contraindications.
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
Donahue JG, Choo PW, Manson JE, Platt R. The incidence of herpes zoster. Arch Intern Med. Aug 1995;155(15):1605-9. [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].
[Best Evidence] Irving G, Jensen M, Cramer M, Wu J, Chiang YK, Tark M, et al. Efficacy and tolerability of gastric-retentive gabapentin for the treatment of postherpetic neuralgia: results of a double-blind, randomized, placebo-controlled clinical trial. Clin J Pain. Mar-Apr 2009;25(3):185-92. [Medline].
Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. Jan 1 2007;44 Suppl 1:S1-26. [Medline].
Beutner KR, Friedman DJ, Forszpaniak C, Andersen PL, Wood MJ. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother. Jul 1995;39(7):1546-53. [Medline].
Colin J, Prisant O, Cochener B, Lescale O, Rolland B, Hoang-Xuan T. Comparison of the efficacy and safety of valaciclovir and acyclovir for the treatment of herpes zoster ophthalmicus. Ophthalmology. Aug 2000;107(8):1507-11. [Medline].
Whitley RJ, Weiss H, Gnann JW Jr, Tyring S, Mertz GJ, Pappas PG, et al. 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].
Tyring S, Engst R, Corriveau C, Robillard N, Trottier S, Van Slycken S, et al. Famciclovir for ophthalmic zoster: a randomised aciclovir controlled study. Br J Ophthalmol. May 2001;85(5):576-81. [Medline].
National Center for Immunization and Respiratory Diseases. Varicella Vaccine - Q&A about High Risk. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/vaccines/vpd-vac/varicella/vac-faqs-clinic-highrisk.htm. Accessed December 11, 2008.
Brody MB, Moyer D. Varicella-zoster virus infection. The complex prevention-treatment picture. Postgrad Med. Jul 1997;102(1):187-90, 192-4. [Medline].
Kost RG, Straus SE. Postherpetic neuralgia--pathogenesis, treatment, and prevention. N Engl J Med. Jul 4 1996;335(1):32-42. [Medline].
Nikkels AF, Pierard GE. Recognition and treatment of shingles. Drugs. Oct 1994;48(4):528-48. [Medline].
Straus SE. Overview: the biology of varicella-zoster virus infection. Ann Neurol. 1994;35 Suppl:S4-8. [Medline].
Wareham DW, Breuer J. Herpes zoster. BMJ. June 2007;334(7605):1211-1215. [Medline].
Wood MJ. Current experience with antiviral therapy for acute herpes zoster. Ann Neurol. 1994;35 Suppl:S65-8. [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].
Further Reading
Keywords
herpes zoster, shingles, zona ignea, zona serpiginosa, zoster, herpesvirus, varicella-zoster virus, VZV, VZV infection, VZV reactivation, varicella-zoster virus infection, zoster sine herpete, chickenpox, chicken pox, vesicular rash, zoster keratitis, Ramsay Hunt syndrome, herpeszosteroticus, transitory unilateral facial paralysis, postherpetic neuralgia, conjunctivitis, keratitis, corneal ulceration, iridocyclitis, glaucoma, peripheral facial nerve weakness, peripheral facial nerve palsy, myelitis, cranial nerve palsies, granulomatous angiitis, disseminated zoster, encephalitis, hepatitis, pneumonitis, tingling, burning, trigeminal neuralgia, herniated nucleus pulposus with radiculopathy, erythematous rash, meningoencephalitis, dorsal root ganglion
