A 55 yo Hispanic male presented reporting pain along the left side of his head for one day, and an early rash. The skin rash was red, with a few vesicles and no lid edema. Vision was 20/20. Fields were full to confrontations, versions were full with no restrictions and pupils were normally reactive without an APD. Slit lamp exam found no chemosis, corneal involvement, or anterior chamber reaction. Vesicles were present on the upper lid. IOP was 19mmHg OD, 19mmHg. Dilated fundus exam found healthy optic nerves, maculae, vessels and intact periphery. The patient was prescribed valacyclovir 1 gm TID PO x 14 days with a Medrol dose pack.

The patient called the next day reporting the eye was swollen shut and the face covered by a rash. The patient was instructed to return to our office to see me as soon as they could get there. On day two, the lids were edematous and nearly shut. The rash covered the top of the head to below the left cheek, and lesions were found inside the mouth on the left side. The patient reported that he has started the valcyclovir but not the Medrol dose pak. Vision was slightly reduced to 20/25. Slit lamp exam found a healthy right eye but severe lid hyperemia and edema, and conjunctival chemosis OS. Cornea and anterior chamber were clear. IOP was 19mmHg OD, 18mmHg. 

After examining the patient, I reviewed his medications. He reported that he has not taken the Medrol dose pack because he had recently finished a Medrol dose pak prescribed by the local emergency room. I flipped back to the previous visit and there was no mention of this in the clinical note. I asked them to tell me what happened that made him go to the ER. The patient reported vision loss in the left eye and severe pain over the temporal side three weeks earlier. He reported the ER doctors drew blood, and “looked at his blood vessel on the left side”. They gave him a steroid shot and a medrol dose pak, and the vision returned a few days later. He reported he thought he was fine until the day before. My impression was they suspected giant cell arteritis at the ER and treated with steroids. The vision returned, but the herpes zoster infection started after he completed the Medrol dose pak. 

Alarm bells went off in my head. If he got the HZO infection on steroids, should he take them again? My gut said no. I was also concerned at the progression of the infection in 24 hours after starting the valcyclovir. I was particularly concerned about the presence of oral mucosal lesions. I contacted our local infectious disease group and asked the question: if a patient develops an HZ infection coming off steroids, is it appropriate to restart steroids to address the current HZ infection? 

Their answer? No. They offered to see the patient, and we sent the patient immediately.  Infectious disease ordered a peripherally inserted central catheter (PICC) and started the patient on IV acyclovir that day. A PICC line is a permanent catheter placed in the cephalic, basilic or brachial vein, and advanced toward the heart until the tip rests in the distal superior vena cava or cavoatrial junction. It is usually inserted by a radiologist to deliver IV medications at home. Home health trained the patient to administer the IV medications and care for the IV line that night. I nervously called the patient the next morning for a status report. He reported a significant reduction in pain and swelling of the face and eye. He was following up with infectious disease the next day. I instructed him to call the office should any symptoms get worse, otherwise see me in 5 days. Thankfully, we avoided corneal involvement and he is doing well with little PHN.

Treatment

The goals of pharmacologic therapy for HZ infection are to shorten the course, provide analgesia, prevent complications, and reduce the incidence of post-herpetic neuralgia.  Management typically includes antivirals and analgesics. Antivirals are used to hasten the healing of the rash and prevent new lesions, reduce viral shedding to reduce risk of transmission to others, and decrease the duration of the neuritis and prevent post-herpetic neuralgia. Initiation of antiviral therapy is recommended within 72 hours of onset of symptoms.1 Oral nucleoside analogues acyclovir, valacyclovir, and famciclovir are the preferred antivirals for treatment of acute herpes zoster infection. Acyclovir is administered five times per day, so for many, the required three daily doses of valacyclovir, and famciclovir are preferred. Care must be taken in patients with renal insufficiency. Immunocompromised patients should receive IV acyclovir even after 72 hours. Patients in the acute phase should be monitored for bacterial superinfection. If lesions appear to be infected at initial presentation or at a later follow-up visit, appropriate oral gram-positive antibacterial treatment should be initiated. 

Pain control is typically the patient’s main concern. While antivirals will reduce pain associated with neuritis, analgesia is often required. Ibuprofen and acetaminophen are often used. Weak opioids such as codeine or tramadol may be used as well, but gabapentin, tricyclic antidepressants or glucocorticoids are not recommended for acute infection. 1 Narcotic and nonnarcotic agents may be used topically and orally. Long term, tricyclic antidepressants have been found to address neuropathic pain. Anticonvulsants (gabapentin) may be beneficial for PHN as well. However, these are not recommended for acute phase treatment. 1 Subcutaneous injection of triamcinolone and lidocaine within the first 7 days of HZ infection reportedly reduced neuralgia at three months more effectively than oral antivirals and analgesics alone.

The use of steroids is debatable, but it’s not uncommon when I have patients referred by the local emergency department. A meta-analysis of five placebo-controlled trials evaluating treatment using acyclovir alone compared to acyclovir plus steroids did not demonstrate a benefit of combination therapy on the patient’s quality of life or the incidence of post-herpetic neuralgia. (update) Steroids also increase the risk of secondary bacterial skin infection. 

Conservative treatment includes nonsteroidal inflammatories, compounded shingles creams, and palliative lotions. I have had great success with compounded creams containing both antiviral and analgesic medications. These are available in various combinations and can be tailored to the desired price point by a creative pharmacist when required. Examples of components include ketamine 5%, acyclovir 5%, lidocaine 2 or 5%, ketoprofen 10%, gabapentin  5%, clonidine 0.2%, baclofen 2%,  amitriptyline 2%, deoxy-D-glucose 0.1%, and diclofenac 3%.  It may be compounded as a cream or gel. These can easily be ordered from a compounding pharmacy be asking the pharmacist for “shingles cream”.

Treatment is of greatest benefit to immunocompromised patients and those older than 50 years. Hospitalization should be considered for those with severe symptoms, immunosuppression, or an atypical presentation such as myelitis or involving more than 2 dermatomes, ophthalmic or meningoencephalopathic involvement. 1 

While most of our patients do not require intravenous medical treatment for HZO, I hope it is helpful to know when to consider this level of treatment. 


  1. MA Albrecht; MS Hirsch; J Mitty. Treatment of herpes zoster in the immunocompetent host.  July 31, 2018.  UpToDate. https://www.uptodate.com/contents/treatment-of-herpes-zoster-in-the-immunocompetent-host. Accessed 9/29/2018.
  2. Ni, X Wang, Y Tang, L Yang, Y Zeng, Y Guo. Subcutaneous Injection of Triamcinolone and Lidocaine to Prevent Postherpetic Neuralgia. Pain Physician. 2017 Jul;20(5):397-403.
  3. JA Santee. Corticosteroids for herpes zoster: what do they accomplish? Am J Clin Dermatol. 2002;3(8):517-24.

  4. N Chen, M Yang, L He, D Zhang, M Zhou, C Zhu. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2010;12:CD005582.

  5. L MacFarlane, MM Simmons, MH Hunter. The Use of Corticosteroids in the Management of Herpes Zoster. RW Force, Editor. STEPPED CARE: AN EVIDENCE-BASED APPROACH TO DRUG THERAPY. JABFP May-June 1998 Vol. 11 No.3.  https://pdfs.semanticscholar.org/e74a/bd01b26b75244320b0f82c86bf1b1339cd7c.pdf  Accessed 9/29/2018.

  6. LV Allen. Compounding for Shingles (Herpes Zoster) Patients. International Journal of Pharmaceutical Compounding. RxTriad. Vol 13, No 2. 2010.  http://www.ijpc.com/rxtriad/pdf/RxTriad_V13_N02_Sample.pdf. Accessed 9/29/2019