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      Drugs & Diseases > Infectious Diseases

      Varicella-Zoster Virus (VZV) Treatment & Management

      Updated: Sep 30, 2022
      • Author: Zartash Zafar Khan, MD, FACP; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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      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 symptom duration 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. [13]

      Acyclovir has two limitations—bioavailability and the existence of some resistant strains of varicella-zoster virus (VZV).

      Other medications, including valacyclovir, penciclovir, and famciclovir, also are 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.

      Persistent lesions after 7 to 10 days of treatment with acyclovir may suggest acyclovir resistance. There are case reports of treatment with Foscarnet in immune compromised patients. [14] Infectious disease specialist consultation is recommended in complicated cases. Thymadine Kinase mutation testing and alternative treatment agents may be needed. 

      Varicella zoster immune globulin (VariZIG) is indicated for administration to high-risk individuals within 10 days (ideally within 4 days) of chickenpox (varicella zoster virus) exposure. [5]

      In July 2013, the CDC issued updated recommendations for the use of varicella-zoster immune globulin (VariZIG) to reduce the severity of VZV infection, extending the window for postexposure prophylaxis for those at high risk for severe varicella. [15, 16] The FDA's original approval of VariZIG recommended use within 4 days, but subsequent studies have shown that the treatment is effective for up to 10 days after exposure.

      Other recommendations include the use of VariZIG in the following patients:

      • Immunocompromised patients without evidence of immunity
      • Newborn infants whose mothers have varicella symptoms between 5 days before and 2 days after delivery
      • Hospitalized premature infants born at 28 weeks of gestation or later whose mothers do not have evidence of immunity to varicella
      • Hospitalized premature infants born at less than 28 weeks of gestation or who weigh less than 1000 g at birth, regardless of their mothers' evidence of immunity to varicella
      • Pregnant individuals without evidence of immunity

      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. [17]

      There is no convincing evidence that use of corticosteroids prevents post herpetic neuralgia. 

      Next:

      Surgical Care

      Surgical care may be required for complications of zoster, such as necrotizing fasciitis.

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      Consultations

      Consultation with a neurologist is indicated in cases of myelitis or encephalitis.

      Consultation with an infectious disease specialist should be considered if bacterial superinfection or viral resistance to acyclovir are suspected and for recurrent zoster. 

      Consultation with an ophthalmologist is indicated upon optic involvement.

      Consultation with a dermatologist may be helpful when the rash is atypical.

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      Prevention

      CDC recommends two doses of varicella (chickenpox) vaccine for children, adolescents, and adults to protect against varicella. Children are routinely recommended to receive the first dose at age 12 through 15 months and the second dose at age 4 through 6 years old.

      In February 2018, the CDC approved the 2018 adult immunization schedules. Changes to the 2018 schedule regarding zoster vaccines includes the following [18, 19] :

      • Administer two doses of recombinant zoster vaccine (RZV) (Shingrix) 2-6 months apart to adults aged 50 years or older regardless of past episodes of herpes zoster or receipt of zoster vaccine live (ZVL) (Zostavax).
      • Administer two doses of RZV 2-6 months apart to adults who previously received ZVL at least 2 months after ZVL.
      • For adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred).

      In October 2017, the FDA approved zoster vaccine recombinant, adjuvanted (Shingrix) for the prevention of shingles in adults aged 50 years or older. The approval is based on findings from a phase III clinical trial program assessing its efficacy, safety, and immunogenicity in 38,000 patients. Data from a pooled analysis of two clinical trials demonstrated efficacy against shingles at greater than 90% across all age groups, as well as sustained efficacy over a follow-up period of 4 years. [20, 21]

       

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