Approach

Infections are usually self-limiting; however, consider antivirals in all patients, especially those who have severe disease and/or are >50 years of age. Because of a higher risk of HZ-related complications, including postherpetic neuralgia, treatment with antivirals is strongly recommended for immunocompromised patients, especially those living with HIV. Treatment aims are to reduce viral replication, manage pain, and reduce postherpetic neuralgia. The treatment of HZ during pregnancy is the same as for any other HZ patient. Among all antivirals, acyclovir has been most extensively studied among pregnant women and is the most commonly used.

Viral replication reduction

Antivirals are used to reduce viral replication in all patients, especially those who have severe disease, are >50 years of age, are immunocompromised, and/or have evidence of trigeminal nerve involvement. Administration shortens the duration of viral shedding, stops the formation of new lesions, prevents ocular complications, and reduces the severity of pain.[78][79][80][81][82]​​​​ Treatment is usually with orally administered antiviral medicines such as aciclovir, famciclovir, and valaciclovir, and is most effective when started within 72 hours after rash onset. Use intravenous aciclovir in patients who cannot tolerate oral medicines. Topical antivirals are not recommended.

Studies comparing the effects on cutaneous and pain end points between famciclovir and valaciclovir found that there are no differences in the efficacy.[81][83] A systematic review of high-quality trials has found that famciclovir and valaciclovir are superior to aciclovir in reducing the likelihood of prolonged pain.[84]

Some meta-analyses of randomised controlled trials have found that treating HZ patients with antiviral therapy reduces the duration or incidence of prolonged pain.[80][83][85][86][87][88][89] However, others have found contrary results.[90][91][92] Famciclovir, valaciclovir, and aciclovir have been shown to be superior to placebo in reducing the amount of time to complete cessation of pain.[80][86][93][94] However, the effect of aciclovir on chronic pain has been less clear in other clinical trials.[91][95]

Immunocompromised patients

HZ infections are more common and often more complicated in immunocompromised patients. The main objective of treatment in these patients is to reduce the incidence of cutaneous and visceral dissemination that can lead to life-threatening complications. It is therefore recommended that immunocompromised patients should promptly receive antiviral therapy within 1 week of rash onset or any time before full crusting of lesions. Treat localised disease with oral valaciclovir, famciclovir, or aciclovir, with close outpatient follow-up. Reserve intravenous aciclovir therapy for patients with disseminated varicella zoster virus infection, ophthalmic involvement, very severe immunosuppression, or the inability to take oral medications.

Pain management

For all patients, analgesics work to reduce pain in the acute phase as well as postherpetic neuralgia, and the type administered will depend on the severity. For mild pain, analgesics such as paracetamol and ibuprofen are appropriate. For severe pain, opioid analgesics are an option. Topically administered lidocaine and nerve blocks have also been reported to be effective.[96][97][98] Lotions containing calamine may also be used on open lesions to reduce pain and pruritus.

Postherpetic pain

The most common complication, suspected if pain persists >30 days after rash onset or cutaneous healing. The pain usually presents as a burning sensation or itching. The severity ranges from mild to debilitating.[2] Patients at least 50 years old have an increased risk for complication and for severe pain.[99] Usually resolves within 6 months; however, patients older than 70 years are at greater risk for longer pain duration.

Treatment is primarily for pain control. Patients with mild-to-moderate pain may be treated with non-steroidal anti-inflammatory drugs or paracetamol, alone or in combination with a weak opioid analgesic.[100][101][102][103][104] Topical capsaicin has also been shown to provide pain relief.[105][106][107][108] For patients with moderate-to-severe pain, a strong opioid analgesic may be considered. Treatment with either a tricyclic antidepressant such as amitriptyline or an anticonvulsant such as gabapentin or pregabalin is also effective.[109][110][111][112] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ] One meta-analysis showed no difference in pain relief between gabapentin and tricyclic antidepressants.[113] For those intolerant of opioids or at high risk for addiction, one or a combination of anticonvulsants, tricyclic antidepressants, or corticosteroids are appropriate.

There are no standard guidelines on which medication to initially use for treatment.[114] These treatments are given as single agents or in combination depending on the severity of pain and the response to treatment.

Eye involvement

Treatment includes the use of antiviral drugs such as aciclovir, famciclovir, or valaciclovir for 7 to 10 days, preferably started within 72 hours of rash onset. Intravenous aciclovir is given as needed for retinitis. Oral antiviral drugs resolve acute disease and inhibit late inflammatory recurrences.[82]​​[115] Other treatment includes pain medicines, antibiotic ophthalmic ointment to protect the ocular surface, and topical corticosteroids. Prompt referral to an ophthalmologist is required for all patients who have eye manifestations. Begin antiviral treatment as soon as possible, and before referral.[3]​​

Therapy for chronic problems includes the following:[3]​​

  • Lubricating, preservative-free artificial tear gels or tears

  • Antibiotic ointment

  • Lateral tarsorrhaphy to protect the corneas (which are often hypoaesthetic/anaesthetic as a result of neuronal damage) from breakdown

  • Continuous-wear, therapeutic soft contact lenses and antibiotic drops

  • Topical corticosteroids and antibiotics for inflammatory disease (iritis, episcleritis, scleritis, and immune keratitis)

  • Dilation for iritis

  • Glaucoma therapy as needed

  • Surgical management as needed: for example, for amniotic membrane transplantation, tissue-adhesive seal ulcers, keratoprosthesis, and glaucoma trabeculectomy.

Chronic pain management is generally similar to that for postherpetic neuralgia.

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