treatment

Last edited 12/2022 and last reviewed 12/2022

Oral antiviral agents together with analgesics are frequently used to manage patients with HZ (1,2,3,4)

• antiviral drugs
• is the first line treatment in HZ and should be initiated within 72 hours of rash onset.
• some experts recommend initiating treatment even after 72 hour if new skin lesions are still appearing or complications of herpes zoster are present
• have been shown to
• reduce acute pain and rash severity
• accelerate rash resolution and reduce the formation of new lesions
• reduce the severity and duration of acute pain.  
• treat if >50 years (post herpatic neuralgia rare if <50 years) and within 72 hours of rash or if 1 of the following (4):
  • active ophthalmic;
  • Ramsey Hunt;
  • eczema;
  • non-truncal involvement;
  • moderate or severe pain;
  • moderate or severe rash
• shingles treatment if not within 72 hours (4):
  • consider starting antiviral drug up to 1 week after rash onset if
    • high risk of severe shingles or continued vesicle formation;
    • older age;
    • immunocompromised;
    • or severe pain
• agents used for treatment in adults
• acyclovir - 800 mg five times daily for seven days, or,
• famciclovir  - 500 mg three times daily for seven days, or,
• valaciclovir  - 1,000 mg three times daily for seven days
• IV acyclovir is recommended for immunocompromised persons who require hospitalization and for persons with severe neurologic complications
• analgesics
• paracetamol, alone or in combination with a weak opioid or tramadol
• adjunctives such as amitryptyline, gabapentin or pregabalin, strong opioids (oxycodone) should be considered if pain does not rapidly respond to opioid analgesics or if opioids are not tolerated (1,2,3)

Use of glucocorticoids for the management of HZ is controversial.

• trials have shown that a tapering course of predisone or prednisolone has led to reduction in acute pain, improved performance of activities of daily living, accelerated early healing
• should be administered together with antivirals (due to their immunosuppressive properties)
• not recommended in patients with hypertension, diabetes mellitus, peptic ulcer disease, or osteoporosis

Prevention of HZ

• a live-attenuated VZV vaccine against HZ administered to adults aged over 50 years, has been shown to reduce the incidence of HZ, PHN and other complications in immunocompetent adults (3)

Reference:

• (1) Cohen JI. Herpes zoster. N Engl J Med. 2013;369(18):1766-7
• (2) Fashner J, Bell AL. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2011;83(12):1432-7. 
• (3) Johnson RW, Alvarez-Pasquin MJ, Bijl M, et al. Herpes zoster epidemiology, management, and disease and economic burden in Europe: a multidisciplinary perspective. Ther Adv Vaccines. 2015;3(4):109-20.
• (4) Public Health England (June 2021). Managing common infections: guidance for primary care