Treatment of Herpes Zoster

Introduction to Treatment

• The recommended first-line treatment for uncomplicated herpes zoster is oral antiviral therapy with valacyclovir 1 gram three times daily for 7 days, as suggested by the Kidney International guidelines 1, 2, 3

Treatment Algorithm Based on Disease Severity

• For uncomplicated herpes zoster, the first-line treatment is valacyclovir 1 gram orally three times daily for 7 days, according to the Kidney International guidelines 1, 2, 3
• Alternative options for uncomplicated herpes zoster include acyclovir 800 mg orally five times daily for 7 days, as recommended by the Kidney International guidelines 1, 2, 3
• For disseminated or invasive herpes zoster, the recommended treatment is intravenous acyclovir 5-10 mg/kg every 8 hours, as suggested by the Kidney International and MMWR Recommendations and Reports guidelines 1, 2, 3, 4
• Temporary reduction in immunosuppressive medication is recommended if applicable, according to the Kidney International guidelines 1, 2, 3
• Treatment should be continued until clinical resolution is attained, as recommended by the MMWR Recommendations and Reports guidelines 4
• Switch to oral therapy once clinical improvement occurs, as suggested by the MMWR Recommendations and Reports guidelines 4

Special Populations

• Consider longer treatment duration if healing is delayed in immunocompromised patients, as recommended by the MMWR Recommendations and Reports guidelines 4
• Monitor closely for dissemination and complications in immunocompromised patients, according to the Kidney International guidelines 1, 2, 3

Prevention of Varicella Zoster in Susceptible Patients

• For varicella-susceptible patients exposed to active varicella zoster infection, varicella zoster immunoglobulin within 96 hours of exposure is recommended, as suggested by the Kidney International guidelines 1, 2, 3
• If immunoglobulin is unavailable or >96 hours have passed, a 7-day course of oral acyclovir begun 7-10 days after exposure is recommended, according to the Kidney International guidelines 1, 2, 3

Pain Management for Herpes Zoster

Special Considerations

• For severe cases or immunocompromised patients, the Infectious Diseases Society of America recommends considering intravenous acyclovir 5-10 mg/kg every 8 hours until clinical improvement, then switching to oral therapy to complete the treatment course 5
• Continuing treatment beyond 7 days may be necessary if new lesions continue to form or healing is incomplete, as suggested by the Clinical Infectious Diseases guidelines 5
• For severe cases with dissemination, switching from oral to intravenous therapy until clinical improvement occurs is recommended by the Clinical Infectious Diseases guidelines 5

Alternative Treatment Options for Shingles

Antiviral Therapy

• The Centers for Disease Control and Prevention recommends intravenous acyclovir 5-10 mg/kg body weight every 8 hours for patients who develop severe disease or complications necessitating hospitalization, such as disseminated infection 6, 7
• Treatment should be continued until clinical resolution is attained, according to the Centers for Disease Control and Prevention 7
• For patients with suspected acyclovir-resistant herpes zoster, foscarnet 40 mg/kg body weight IV every 8 hours may be required, as suggested by the Centers for Disease Control and Prevention 8, 7
• Desensitization to acyclovir may be considered in consultation with an allergy specialist for patients who experience adverse reactions to both valacyclovir and acyclovir, according to the Centers for Disease Control and Prevention 8, 7

Oral Antiviral Alternatives

• Both acyclovir and famciclovir have more favorable dosing schedules than the five-times-daily regimen required for acyclovir, as noted by the Centers for Disease Control and Prevention 6, 7

Herpes Zoster Prevention and Treatment

Vaccination Recommendations

• The Centers for Disease Control and Prevention (CDC) recommends the recombinant zoster vaccine (Shingrix) for adults aged 50 years and older regardless of prior episodes of herpes zoster, as it is preferred over zoster vaccine live (ZVL) for the prevention of herpes zoster and related complications 9
• Vaccination is strongly recommended for patients 50 years of age and older without contraindications, according to the CDC guidelines 9

Treatment for Herpes Zoster

Treatment Course

• Treatment should be prescribed within 72 hours of rash onset when possible and should continue for a minimum of 7-10 days 10
• Delayed initiation of treatment beyond 72 hours of rash onset may reduce effectiveness 10
• Immunosuppressive therapy should be discontinued in severe cases of varicella infection, disseminated HSV and VZV 10

Treatment of Herpes Zoster with Antiviral Therapy

Severe or Complicated Disease

• For disseminated, multi-dermatomal, ophthalmic, visceral, or complicated herpes zoster, intravenous acyclovir 5-10 mg/kg every 8 hours is recommended, with treatment continuing for a minimum of 7-10 days and until clinical resolution is attained, as suggested by the Journal of Crohn's and Colitis guidelines 11
• Treatment should be continued until clinical improvement occurs, then switched to oral therapy to complete the treatment course, with the goal of reducing the duration and severity of acute pain and preventing complications 11

Management in Immunocompromised Patients

• All immunocompromised patients with herpes zoster require antiviral treatment regardless of timing, and may need to temporarily discontinue or reduce immunosuppressive therapy in severe cases of disseminated VZV infection, as recommended by the Journal of Crohn's and Colitis guidelines 11
• Immunosuppression may be restarted after the patient has commenced anti-VZV therapy and skin vesicles have resolved, with close monitoring for dissemination and visceral complications 11

Acyclovir-Resistant Cases

• For suspected acyclovir-resistant herpes zoster, foscarnet 40 mg/kg IV every 8 hours is recommended, as acyclovir-resistant isolates are routinely resistant to ganciclovir as well, according to the MMWR Recommendations and Reports guidelines 12

Alternatives to Acyclovir for Gastrointestinal Intolerance

Introduction to Alternative Treatments

• The American College of Physicians recommends famciclovir as the first-line alternative to acyclovir for patients with gastrointestinal intolerance, with a dose of 500 mg every 12 hours for recurrent herpes simplex or 500 mg every 8 hours for herpes zoster 13

Treatment Options

• For recurrent herpes simplex, famciclovir 500 mg every 12 hours is effective and well-tolerated, according to the Centers for Disease Control and Prevention 13
• For herpes zoster, famciclovir 500 mg every 8 hours for 7-10 days is recommended by the Infectious Diseases Society of America 13
• For chronic suppression, famciclovir 125-250 mg daily may be used in patients with frequent recurrences, as suggested by the American Academy of Dermatology 13

Intravenous Therapy for Severe Cases

• Foscarnet 40 mg/kg IV every 8 hours is effective for severe or disseminated infections where oral therapy is not tolerated, according to the National Institutes of Health 13
• Foscarnet requires close monitoring of renal function and electrolytes (hypocalcemia, hypophosphatemia, hypomagnesemia, hypokalemia), as recommended by the European Society of Clinical Microbiology and Infectious Diseases 14

Special Considerations

• In patients with renal impairment, famciclovir requires dose adjustment, with a recommended dose of 500 mg every 24 hours for creatinine clearance 20-39 mL/min, as suggested by the National Kidney Foundation 13
• For pregnant women, famciclovir is category B and may be considered for severe and frequent recurrences, according to the American College of Obstetricians and Gynecologists 13, 15
• In immunocompromised patients, famciclovir 500 mg every 12 hours is effective, and close monitoring for dissemination and visceral complications is recommended by the Infectious Diseases Society of America 16

Duration of Antiviral Therapy for Shingles

Treatment Duration and Endpoint

• The American Academy of Dermatology recommends continuing acyclovir until all lesions have completely scabbed, with treatment duration determined by lesion healing status, not by the timing of prednisone discontinuation, and a minimum guideline of 7-10 days 17

Special Considerations

• In the context of post-exposure prophylaxis, a 7-day course of oral acyclovir beginning 7-10 days after varicella exposure is recommended when immunoglobulin is unavailable or >96 hours have passed, as suggested by the Infectious Diseases Society of America 17