Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute symptoms: immunocompetent

1st line – oral antiviral therapy

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ACUTE
|
acute symptoms: immunocompetent
1st line – 

oral antiviral therapy

Antivirals shorten the duration of viral shedding, stop the formation of new lesions, and reduce pain severity. Treatment is usually with orally administered antiviral medicines such as aciclovir, famciclovir, and valaciclovir. Start within 48 to 72 hours of rash onset and administer for 7 days (up to 10 days in patients with eye manifestations). A systematic review of high-quality trials has found that famciclovir and valacyclovir were superior to acyclovir in reducing the likelihood of prolonged pain.[84]

Primary options

famciclovir: 500 mg orally every 8 hours for 7 days

OR

valaciclovir: 1000 mg orally every 8 hours for 7 days

Secondary options

aciclovir: 800 mg orally five times daily for 7-10 days; 10 mg/kg intravenously every 8 hours for 7 days

Plus – simple analgesics ± calamine lotion

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ACUTE
|
acute symptoms: immunocompetent
|
mild pain
Plus – 

simple analgesics ± calamine lotion

Treatment recommended for ALL patients in selected patient group

The type of analgesics administered will depend on the severity of the pain.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

or

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

-- AND --

calamine lotion topical: apply to the affected area(s) up to four times daily when required

Consider – opioid analgesics ± topical analgesic

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ACUTE
|
acute symptoms: immunocompetent
|
moderate-to-severe pain
Consider – 

opioid analgesics ± topical analgesic

Additional treatment recommended for SOME patients in selected patient group

The type of analgesics administered will depend on the severity of pain.

Primary options

oxycodone: 5 mg orally (immediate-release) every 4-6 hours when required

Secondary options

oxycodone: 5 mg orally (immediate-release) every 4-6 hours when required

-- AND --

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

or

calamine lotion topical: apply to the affected area(s) up to four times daily when required

Plus – prompt referral to ophthalmologist

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ACUTE
|
acute symptoms: immunocompetent
|
eye involvement
Plus – 

prompt referral to ophthalmologist

Treatment recommended for ALL patients in selected patient group

Prompt referral to an ophthalmologist is required for all patients who have eye manifestations.[3]​​

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. Systemic corticosteroids may be indicated in moderate-to-severe pain, especially if there is oedema surrounding the orbital area.[3]​​

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

acute symptoms: immunocompromised

1st line – oral antiviral therapy

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ACUTE
|
acute symptoms: immunocompromised
|
localised disease with no eye involvement or not severely immunocompromised
1st line – 

oral antiviral therapy

Immunocompromised patients should promptly receive antiviral therapy within 1 week of rash onset or any time before full crusting of lesions. Localised disease should be treated with oral valaciclovir, famciclovir, or aciclovir, with close outpatient follow-up.

Primary options

aciclovir: 800 mg orally five times daily for 7-10 days; 10 mg/kg intravenously every 8 hours for 7 days

OR

famciclovir: 500 mg orally every 8 hours for 7 days

OR

valaciclovir: 1000 mg orally every 8 hours for 7 days

Plus – simple analgesics ± calamine lotion

Back
ACUTE
|
acute symptoms: immunocompromised
|
localised disease with no eye involvement or not severely immunocompromised
Plus – 

simple analgesics ± calamine lotion

Treatment recommended for ALL patients in selected patient group

The type of analgesics administered will depend on the severity of the pain.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

or

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

-- AND --

calamine lotion topical: apply to the affected area(s) up to four times daily when required

Consider – opioid analgesics ± topical analgesic

Back
ACUTE
|
acute symptoms: immunocompromised
|
localised disease with no eye involvement or not severely immunocompromised
Consider – 

opioid analgesics ± topical analgesic

Additional treatment recommended for SOME patients in selected patient group

The type of analgesics administered will depend on the severity of pain.

Primary options

oxycodone: 5 mg orally (immediate-release) every 4-6 hours when required

Secondary options

oxycodone: 5 mg orally (immediate-release) every 4-6 hours when required

-- AND --

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

or

calamine lotion topical: apply to the affected area(s) up to four times daily when required

2nd line – intravenous aciclovir

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ACUTE
|
acute symptoms: immunocompromised
|
localised disease with no eye involvement or not severely immunocompromised
2nd line – 

intravenous aciclovir

If the patient is unable to tolerate oral medication, intravenous aciclovir can be given.

Primary options

aciclovir: 10 mg/kg intravenously every 8 hours for 7 days

Plus – simple analgesics ± calamine lotion

Back
ACUTE
|
acute symptoms: immunocompromised
|
localised disease with no eye involvement or not severely immunocompromised
Plus – 

simple analgesics ± calamine lotion

Treatment recommended for ALL patients in selected patient group

The type of analgesics administered will depend on the severity of the pain.

Primary options

paracetamol: oral/rectal: 500-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<50 kg body weight): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; intravenous (≥50 kg body weight): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

OR

diclofenac sodium: 37.5 mg intravenously every 6 hours when required, maximum 150 mg/day

Secondary options

paracetamol: oral/rectal: 500-1000 mg orally/rectally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<50 kg body weight): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; intravenous (≥50 kg body weight): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

or

diclofenac sodium: 37.5 mg intravenously every 6 hours when required, maximum 150 mg/day

-- AND --

calamine lotion topical: apply to the affected area(s) up to four times daily when required

Consider – opioid analgesics ± topical analgesic

Back
ACUTE
|
acute symptoms: immunocompromised
|
localised disease with no eye involvement or not severely immunocompromised
Consider – 

opioid analgesics ± topical analgesic

Additional treatment recommended for SOME patients in selected patient group

The type of analgesics administered will depend on the severity of pain.

Primary options

oxycodone: 5 mg orally (immediate-release) every 4-6 hours when required

Secondary options

oxycodone: 5 mg orally (immediate-release) every 4-6 hours when required

-- AND --

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

or

calamine lotion topical: apply to the affected area(s) up to four times daily when required

1st line – intravenous aciclovir

Back
ACUTE
|
acute symptoms: immunocompromised
|
disseminated disease or eye involvement or severe immunosuppression
1st line – 

intravenous aciclovir

Intravenous aciclovir therapy should be reserved for patients with disseminated infection, ophthalmic involvement, or very severe immunosuppression.

Primary options

aciclovir: 10 mg/kg intravenously every 8 hours for 7 days

Consider – opioid analgesics ± topical analgesic

Back
ACUTE
|
acute symptoms: immunocompromised
|
disseminated disease or eye involvement or severe immunosuppression
Consider – 

opioid analgesics ± topical analgesic

Additional treatment recommended for SOME patients in selected patient group

The type of analgesics administered will depend on the severity of pain.

Primary options

oxycodone: 5 mg orally (immediate-release) every 4-6 hours when required

Secondary options

oxycodone: 5 mg orally (immediate-release) every 4-6 hours when required

-- AND --

lidocaine topical: (5% ointment) apply to the affected area(s) two to three times daily when required

or

calamine lotion topical: apply to the affected area(s) up to four times daily when required

ONGOING

postherpetic pain

1st line – paracetamol or NSAID

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ONGOING
|
postherpetic pain
|
mild pain
1st line – 

paracetamol or NSAID

Patients with mild-to-moderate pain should be treated with non-steroidal anti-inflammatory drugs (NSAIDs) or paracetamol, alone or in combination with a weak opioid analgesic.[100][101][102][103][104]

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Consider – weak opioid analgesic

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ONGOING
|
postherpetic pain
|
mild pain
Consider – 

weak opioid analgesic

Additional treatment recommended for SOME patients in selected patient group

Patients with mild-to-moderate pain should be treated with non-steroidal anti-inflammatory drugs or paracetamol, alone or in combination with a weak opioid analgesic.[100][101][102][103][104]

Primary options

codeine phosphate: 15-60 mg orally every 4-6 hours when required, maximum 240 mg/day

2nd line – topical capsaicin

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ONGOING
|
postherpetic pain
|
mild pain
2nd line – 

topical capsaicin

Topical capsaicin has also been shown to provide pain relief.[105][106][107][108]

Primary options

capsaicin topical: (0.025 to 0.075%) apply to the affected area(s) three to four times daily

1st line – strong opioid, amitriptyline, or anticonvulsant

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ONGOING
|
postherpetic pain
|
moderate-to-severe pain
1st line – 

strong opioid, amitriptyline, or anticonvulsant

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 of addiction, one or a combination of anticonvulsants, tricyclic antidepressants, or corticosteroids is appropriate.

Primary options

tramadol: 50-100 mg orally every 4-6 hours when required, maximum 400 mg/day

OR

oxycodone: 5 mg orally (immediate-release) every 4-6 hours when required

Secondary options

amitriptyline: 0.5 to 2 mg/kg orally once daily at bedtime initially, increase according to response, maximum 150 mg/day

OR

gabapentin: 300 mg orally three times daily initially, increase according to response, maximum 1800 mg/day

OR

pregabalin: 300 mg/day orally given in 2-3 divided doses

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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