Guidelines Summary
The following organizations have issued guidelines for the management of herpes zoster and its complications:
Therapy and Prophylaxis Guidelines
The 2007 International Association for the Study of Pain (IASP) recommendations for the management of herpes zoster offer the most comprehensive guidance covering treatment of both immunocompromised and immunocompetent patients.
IASP recommendations for immunocompetent patients are as follows [1] :
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Topical antiviral therapy is not recommended.
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Oral antiviral therapy is recommended for first-line treatment for patients 50 years or older, moderate or severe pain, moderate or severe rash, or those who have non truncal involvement.
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Oral antiviral therapy should be considered for patients younger than 50 years with mild pain and rash and truncal involvement because of the risk of developing postherpetic neuralgia (PHN).
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Brivudin, famciclovir, and valacyclovir show greater efficacy than acyclovir.
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Antiviral therapy should be initiated within 72 hours of the onset of the rash, but it may be considered for patients presenting more than 72 hours after the onset of the rash when there are cutaneous, motor, neurologic, or ocular complications or in patients of advanced age or in severe pain.
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Pain management approaches should be individualized based on pain severity, underlying conditions, and prior response to specific medications.
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For mild to moderate pain, acetaminophen or NSAIDs may be used alone or in combination with weak opioids such as codeine or tramadol.
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For moderate to severe pain, strong opioids such as oxycodone or morphine may be used.
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If moderate to severe pain has not responded rapidly to treatment with an opioid analgesic, the addition of gabapentin or pregabalin, tricyclic antidepressants (TCAs) (especially nortriptyline), or corticosteroids (eg, prednisone) may be considered.
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For those patients with moderate or severe pain who are unable to tolerate an opioid analgesic, treatment with gabapentin or pregabalin, TCAs (especially nortriptyline), or corticosteroids (eg, prednisone), alone and in combination, can be considered.
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For patients with pain that is inadequately controlled by antiviral agents in combination with oral analgesic medications and/or corticosteroids, referral to a pain specialist to evaluate eligibility for neural blockade.
IASP recommendations for immunocompromised patients are as follows [1] :
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Intravenous acyclovir is the therapy of choice for allogeneic hematopoietic stem cell transplant recipients within 4 months of transplantation, hematopoietic stem cell transplant recipients with moderate-to-severe acute or chronic graft versus host disease, or any transplant recipient receiving aggressive antirejection therapy.
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For less severely immunosuppressed patients, oral therapy with acyclovir, valacyclovir, or famciclovir, coupled with close clinical observation, is a reasonable option.
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Brivudin is not recommended for patients undergoing chemotherapy with 5-fluoropyrimidines.
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For highly immunocompromised patients who present with herpes zoster ophthalmicus, intravenous acyclovir and evaluation by an ophthalmologist is recommended.
The 2011 American Academy of Family Physicians (AAFP) guidelines include the following key recommendations [136] :
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Antiviral therapy should be initiated within 72 hours of the onset of the rash in patients with acute herpes zoster (level A).
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Based on individual patient characteristics, a TCA, tramadol, long-acting opioid, or anticonvulsant (ie, gabapentin or pregabalin) should be selected to decrease the pain of PHN (level A).
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Capsaicin cream or a lidocaine patch may decrease pain in patients with PHN (level B).
In its 2014 update of practice guidelines for the diagnosis and management of skin and soft tissue infections, the Infectious Disease Society of America (IDSA) offered recommendations for management in immunocompromised patients. Recommendations include the following [137] :
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The treatment of choice is high-dose intravenous acyclovir for immunocompromised patients.
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Oral acyclovir, famciclovir, and valacyclovir is recommended for mild cases in patients with transplant immune suppression or for patients who have shown a clinical response to intravenous acyclovir.
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Recipients of bone marrow transplants should take oral acyclovir or valacyclovir during the first year for prevention of herpes zoster.
Herpes Zoster Ophthalmicus Guidelines
The 2007 International Association for the Study of Pain (IASP) recommendations for the management of herpes zoster ophthalmicus are as follows [1] :
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Famciclovir or valacyclovir for 7-10 days, with intravenous acyclovir given as needed for retinitis
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Pain medications, as for immunocompetent patients
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Cool-to-tepid wet compresses (if tolerated)
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Antibiotic ophthalmic ointment administered twice daily (eg, bacitracin-polymyxin) to protect the ocular surface
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Topical steroids (eg, 0.125-1% prednisolone 2-6 times daily) prescribed and managed only by an ophthalmologist for corneal immune disease, episcleritis, scleritis, or iritis
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No topical antivirals
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Mydriatic/cycloplegia as needed for iritis (eg, 5% homatropine twice daily)
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Ocular pressure–lowering drugs given as needed for glaucoma
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Systemic steroids indicated in the presence of moderate to severe pain or rash
Postherpetic Neuralgia Guidelines
The 2004 American Academy of Neurology (AAN) practice parameter for the treatment of postherpetic neuralgia (PHN) was last reaffirmed in 2008 and includes the following recommendations [139] :
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Tricyclic antidepressants (TCAs) (eg, amitriptyline, nortriptyline, desipramine, and maprotiline), gabapentin, pregabalin, opioids, and topical lidocaine patches are effective in the treatment of PHN (level A, class I and II).
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Preservative-free intrathecal methylprednisolone may be considered in the treatment of PHN if available (level A, class I and II).
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No benefit was found with the use of acupuncture, benzydamine cream, dextromethorphan, indomethacin, epidural methylprednisolone, epidural morphine sulfate, iontophoresis of vincristine, lorazepam, vitamin E, and zimelidine (level B, class II).
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Unproven interventions include carbamazepine, nicardipine, biperiden, chlorprothixene, ketamine, He:Ne laser irradiation, intralesional triamcinolone, cryocautery, topical piroxicam, extract of Ganoderma lucidum, dorsal root entry zone lesions, and stellate ganglion block (level U, single class II study and class IV studies).
In 2010, the European Federation of Neurological Societies (EFNS) updated its 2005 guidelines on the pharmacological treatment of neurological pain, which included the following recommendations for the treatment of PHN [140] :
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TCA or gabapentin/pregabalin is recommended as first-line treatment (level A).
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Topical lidocaine (level A, less consistent results) may be considered first line in elderly patients, especially if there are concerns regarding the adverse CNS effects with oral medications.
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Strong opioids (level A) and capsaicin cream are second-line choices.
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Capsaicin patches show promise (level A), but the long-term effects of repeated applications, particularly on sensation, are unclear.
Herpes Zoster Prevention Guidelines
Starting in 2008, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommended routine vaccination of all people 60 years or older with a single-dose zoster vaccine. Zoster vaccination is not indicated to treat acute herpes zoster or postherpetic neuralgia (PHN) or to prevent the development of PHN in patients with acute herpes zoster. Serologic testing for varicella immunity is not required prior to vaccination. In 2011 and 2013, after a review of the cost-benefit analysis, the ACIP declined to recommend the vaccine be administered to persons aged 50-59 years. [141]
Additional 2018 recommendations include the following [127] :
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The preferred (RZV) zoster vaccine may be given simultaneously with other vaccines recommended for people 60 years or older, such as the Td, Tdap, and pneumococcal polysaccharide vaccines.
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Zoster vaccination is not recommended for persons of any age who have received varicella vaccine.
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Patients with a history of herpes zoster can be vaccinated.
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For patients initiating immunosuppressant treatments, the zoster vaccine should be given at least 14 days before the initiation of immunosuppressive therapy
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Acyclovir, famciclovir, or valacyclovir should be discontinued at least 24 hours before administration of the "live virus" zoster vaccine, if possible. These medications should not be used for at least 14 days after vaccination, by which time the immunologic effect should be established. Note this does not apply in the use of the new recombinant zoster vaccine.
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The zoster vaccine is contraindicated for persons who have a history of an anaphylactic reaction to any component of the vaccine, including gelatin and neomycin.
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The zoster vaccine should not be administered to persons with primary or acquired immunodeficiency.
The 2013 Infectious Disease Society of America (IDSA) clinical practice evidence-based guidelines for vaccination of immunocompromised patients includes the following recommendations for the vaccine [138] :
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The zoster vaccine should be given to patients 60 years and older if it can be administered 4 weeks or more before beginning highly immunosuppressive therapy (strong, low).
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The zoster vaccine should be given to patients aged 60 years and older who are receiving therapy considered to induce a low level of immunosuppression (strong, low).
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The zoster vaccine is not recommended for highly immunocompromised patients (strong, very low).
The IDSA differs from the CDC ACIP in recommending that the zoster vaccine should be considered for patients with a history of varicella or zoster infection or who are varicella–zoster virus seropositive with no previous doses, aged 50-59 years, if it can be administered 4 weeks or more before beginning immunosuppressive therapy (weak, low).
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Typical zoster in the vicinity of right popliteal fossa in a vertebral nerve L4 distribution.
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Suspected zoster of the hand.
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Herpes zoster, unilateral, on trunk.
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Herpes zoster on lateral part of abdomen.
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Maculopapular rash due to herpes zoster in child with history of leukemia. Image courtesy of Centers for Disease Control and Prevention (CDC).
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Herpes zoster in ophthalmic (V1) distribution of trigeminal nerve. Note unilateral distribution of rash and how V1 distribution may extend to tip of nose. Though at risk for keratitis with zoster in this distribution, patient had normal ocular examination. Patient consented to picture distribution for educational use; written permission on file. Image courtesy of JS Huff.
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Herpes zoster on neck.
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What is herpes? Herpes is a virus causing sores most commonly around the mouth (oral herpes) and genitals (genital herpes).
