Herpes zoster medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; L. Katie Morrison, MD; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Monalisa Dmello, M.B,B.S., M.D. [3]

Overview

Several antiviral medicines—acyclovir, valacyclovir, and famciclovir—are available to treat shingles. These medicines will help shorten the length and severity of the illness. But to be effective, they must be started as soon as possible after the rash appears. Thus, people who have or think they might have shingles should call their healthcare provider as soon as possible to discuss treatment options. Analgesics (pain medicine) may help relieve the pain caused by shingles. Wet compresses, calamine lotion, and colloidal oatmeal baths may help relieve some of the itching.

Medical Therapy

Antimicrobial Regimen

• 1. Varicella zoster treatment

• 1.1 Non Immunocompromised person

• Preferred regimen (1): Acyclovir 500 mg PO five times a dayfor 7-10 days
• Preferred regimen (2): Famciclovir 500 mg PO tid for 7 days
• Preferred regimen (3): Valacyclovir 1 g PO tid for 7 days
• Preferred regimen (4): Brivudin 125 mg PO qd for 7 days

• 1.2 Immunocompromised person requiring hospitalization or persons with sever neurologic complications

• Preferred regimen (1): Acyclovir 10 mg/ kg IV q8h for 7-10 days
• Preferred regimen (2): Foscarnet 40 mg/ kg IV q8h until lesions are healed
• Note: Brivudin is not available in USA and has not been approved by FDA. Foscarnet is not approve by FDA

• 2. Treatment of VZV complications

• 2.1 VZV ophthalmicus

• Treatment includes the following

• (1) Famciclovir OR Valacyclovir for 7–10 days, preferably started within 72 h of rash onset (with Acyclovir IV given as needed for retinitis), to resolve acute disease and inhibit late inflammatory recurrences, AND Prednisone 20 mg PO tid for 4 days or bid for 6 days, and then qd for 4 day
• (2) Bacitracin-Polymyxin ophthalmic ointment administered bid ,to protect the ocular surface;
• (3) Topical Prednisolone 0.125%–1% 2–6 times daily prescribed and managed only by an ophthalmologist for corneal immune disease, episcleritis, scleritis, or iritis;
• (4) Homatropine 5% bid as needed for iritis
• (5) Latanaprost qd and/or Timolol maleate ophthalmic gel forming solution every morning)ocular pressure–lowering drugs given as needed for glaucoma
• Note (1): Systemic steroids are indicated in the presence of moderate to severe pain or rash, particularly if there is significant edema, which may cause orbital apex syndrome through pressure on the nerves entering the orbit.
• Note (2): pain medications and cool to tepid wet compresses (if tolerated) and no topical antivirals, because they are ineffective

• 2.2 VZV retinitis

• Preferred regimen: Acyclovir IV 10–15 mg/kg q8h for 10–14 days followed by Valacyclovir PO 1 g tid daily for 4–6 weeks

• 3 Recommendations for treating varicella zoster virus (VZV) Infections in HIV-Infected adults and adolescents

• 3.1 Herpes Zoster (Shingles)

• 3.1.1 Acute Localized Dermatomal

• Preferred regimen (1): Valacyclovir 1000 mg PO tid for 7–10 days
• Preferred regimen (2): Famciclovir 500 mg PO tid for 7–10 days
• Alternative Therapy: Acyclovir 800 mg PO 5 times daily for 7–10 days
• Note: Longer duration should be considered if lesions resolve slowly

• 3.1.2 Extensive Cutaneous Lesion or Visceral Involvement

• Preferred regimen: Acyclovir 10–15 mg/kg IV q8h until clinical improvement is evident, then switch to (Valacyclovir 1 g PO tid, Famciclovir 500 mg PO tid, or Acyclovir 800 mg PO 5 times daily)—to complete a 10–14 day course, when formation of new lesions has ceased and signs and symptoms of visceral VZV infection are improving

• 3.2 PORN (Progressive outer retinal necrosis)

• Preferred regimen: Ganciclovir 5 mg/kg and/or Foscarnet 90 mg/kg IV q12h AND Ganciclovir 2 mg/0.05mL and/or foscarnet 1.2 mg/0.05mL intravitreal twice weekly.
• Note: Duration of therapy is not well defined and should be determined based on clinical, virologic, and immunologic response in consultation with experienced ophthalmologist and optimize ART regimen.
• Note: Ganciclovir ocular implants are no longer commercially available

• 3.3 ARN (Acute retinal necrosis)

• Preferred regimen: Acyclovir 10-15 mg/kg IV q8h for 10–14 days, followed by Valacyclovir 1 g PO tid for 6 weeks AND Ganciclovir 2 mg/0.05mL intravitreal qd/bid twice weekly
• Note: Duration of therapy is not well defined and should be determined based on clinical, virologic, and immunologic response in consultation with experienced ophthalmologist