HERPES ZOSTER - Treatment

By SWA

Infection: Herpes zoster (immunocompetent host)

  • Drug: Valacyclovir
    • Route: Oral
    • Dosage: 1 g tid × 7 days
  • Drug: Famciclovir
    • Route: Oral
    • Dosage: 500 mg q8h × 7 days
  • Drug: Acyclovir
    • Route: Oral
    • Dosage: 800 mg 5 times daily × 7–10 days

Infection: Herpes zoster (immunocompromised host)

  • Drug: Acyclovir
    • Route: IV
    • Dosage: 10 mg/kg q8h × 7 days
    • Dosage: 800 mg 5 times daily × 7 days
  • Drug: Valacyclovir
    • Route: Oral
    • Dosage: 1 g tid × 7 days
  • Drug: Famciclovir
    • Route: Oral
    • Dosage: 500 mg tid × 10 days

Key Notes:

  • Acyclovir, Valacyclovir, and Famciclovir are the three antivirals commonly used to treat Herpes Zoster (HZ). However, valacyclovir and famciclovir have superior pharmacokinetics and pharmacodynamics and should be used preferentially.
  • Corticosteroids should be added to therapy for HZ in immunocompetent patients. Steroids administered early in the course of localized herpes zoster significantly accelerated quality-of-life improvements as a return to usual activity and termination of analgesic medications.

PREDNISOLONE Dosage Schedule:

  • Days 1-7: 60 mg/day
  • Days 8-14: 30 mg/day
  • Days 15-21: 15 mg/day, then stop

Important Warnings:

  • Glucocorticoids should not be used without concomitant antiviral therapy.
  • Steroids should not be used in patients with HZ who have hypertension, osteoporosis, diabetes mellitus, or are immunocompromised.

Special Considerations for Severely Immunocompromised Hosts:

  • Start treatment with IV acyclovir.
  • If possible, decrease immunosuppressive treatment with IV acyclovir administration.
  • Switch to oral therapy (Valacyclovir 1 g three times a day, Famciclovir 500 mg three times a day, or Acyclovir 800 mg orally five times a day to complete a 10-14-day course) when formation of new lesions has ceased and signs and symptoms of visceral VZV infection are improving.
  • For acyclovir-resistant cases, use Foscarnet 120 mg/kg/day IV in three divided doses for a minimum of 10 days or until lesions heal.

Additional Pain Relief Measures:

  • Aluminum acetate soaks
  • NSAIDs
  • Narcotics
  • Gabapentin
  • Pregabalin
  • Amitriptyline hydrochloride
  • Lidocaine (patches)
  • Fluphenazine hydrochloride

Management of Specific Conditions:

  • Herpes Zoster Ophthalmicus: Managed by an ophthalmologist.
  • Herpes Zoster Oticus: Managed by an otorhinolaryngologist.

Sources:

  1. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 9th Edition
  2. National AIDS Control Organization (2021), National Guidelines for HIV Care and Treatment
  3. Harrison's Principles of Internal Medicine, 21st Edition 

Note: By reading my blog, you acknowledge that I do not provide medical diagnoses or treatments. The information provided is meant to answer frequently asked questions and is gathered from reputable scientific papers. 

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