Zoster: immunocompetent host

• General
  • Hygiene and skin care
    • Aluminum acetate soaks
    • Lotions
• Oral antiviral therapy
  • Increases the rate of healing and decreases the pain caused by the acute rash
  • Most beneficial when initiated within 72 hours of symptom onset
  • Acyclovir 800 mg 5 times daily for 7–10 days or
  • Famciclovir 500 mg tid for 7 days or
  • Valacyclovir 1 g tid for 5–7 days

Zoster: immunocompromised host

• Severely immunocompromised hosts (e.g., transplant recipients, patients with lymphoproliferative malignancies, AIDS patients)
  • Oral acyclovir therapy is not recommended.
  • Intravenous antiviral therapy
    • Acyclovir 10–12.5 mg/kg q8h for 7 days
  • Attempt to wean from any preexisting immunosuppressive treatment
• Low-risk immunocompromised hosts
  • Oral therapy with valacyclovir or famciclovir appears beneficial.

Acute neuritis and postherpetic neuralgia

• Analgesics
  • Nonnarcotics, especially NSAIDs
  • Narcotic derivatives
• Additional medications that may be beneficial for pain relief are:
  • Gabapentin
    • Titrate gradually from 300 mg on day 1 to 300 mg bid on day 2 to 300 mg tid on day 3, to a maximum of 3500 mg/day.
    • Benefit is often seen several weeks after initiating therapy.
  • Amitriptyline
    • Start at 10–25 mg daily, gradually increasing to 50–75 mg daily over 2– 3 weeks.
  • Venlafaxine[1]
    • Start at 75 mg/day in 2–3 divided doses; may increase by up to 75 mg/day every 4 days, up to 225 mg/day (not to exceed 375 mg/day in 3 divided doses)
    • In studies of this drug for neuropathic pain, the higher doses (at least 150–225 mg/day) are often necessary to get a good effect.
  • 5% lidocaine patches
    • Applied locally over affected region of skin
  • Oral glucocorticoids (for acute neuritis during active zoster, not postherpetic neuralgia)
    • May decrease duration of acute pain and shorten time of return to usual activity, but there is no clear benefit in reducing risk of developing postherpetic neuralgia.
    • Given likely marginal benefit, older patients with underlying comorbid conditions (e.g., diabetes mellitus, hypertension, osteoporosis) are poor candidates for glucocorticoid therapy.
    • Should consider only in healthy patients with moderate or severe pain at presentation
    • Typical dosing schedule for prednisone
      • 60 mg/d on days 1–7
      • 30 mg/d on days 8–14
      • 15 mg/d on days 15–21
    • Should not be given without concurrent antiviral therapy