Antiviral Management of Herpes Zoster in High‑Risk Populations

Immunocompromised Patients

High‑dose intravenous acyclovir is the preferred therapy for immunocompromised patients with herpes zoster, especially when disease is multi‑dermatomal, ophthalmic, visceral, or disseminated; treatment should continue for a minimum of 7–10 days until lesions have resolved. 1, 2
For uncomplicated dermatomal zoster in immunocompromised hosts, standard oral doses of valacyclovir or famciclovir may be used as an alternative to IV therapy. 3
The antiviral course in immunocompromised patients should be at least 7–10 days and extended until all vesicles have healed. 3
In cases of severe varicella infection or disseminated VZV, immunosuppressive medications should be stopped. 3
Clinicians should actively monitor for complications such as bacterial superinfection, systemic dissemination, or neurologic involvement while on antiviral therapy. 1, 2
Persistent lesions despite appropriate antiviral treatment in immunocompromised patients warrant evaluation for acyclovir resistance. 3

Adults living with HIV have a >15‑fold higher incidence of herpes zoster compared with the general population (CDC recommendation). 4
Standard oral antiviral regimens (valacyclovir, famciclovir, or acyclovir) are recommended for HIV‑infected patients, with close clinical monitoring. 4
The minimum duration of antiviral therapy in HIV‑infected individuals is 7–10 days. 4

Ongoing assessment of treatment response should occur within 48–72 hours of initiating antivirals, with particular attention to signs of bacterial superinfection, dissemination, or neurologic complications. 1, 2
If lesions do not improve as expected, consider the possibility of antiviral resistance, especially in immunocompromised patients. 3