Herpes Zoster Infection in Adults
|Last review: 22/02/2017|
|Next review: 22/02/2020|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the management of herpes zoster infection in adults
Two clinical trials showed a 3 week reducing course of prednisolone had some beneficial effect on acute pain and rash healing. [1, 2] In 1 of these studies, the time to return of normal activity and cessation of analgesics was accelerated in those receiving steroids.  However, there was no significant benefit with regard to treatment of chronic pain. [1, 2] Patients with contraindications to steroids were excluded from these trials, but despite this, adverse effects were reported. A subsequent meta-analysis of five placebo-controlled trials comparing aciclovir and steroid to aciclovir alone did not show a significant difference between the groups in preventing post-herpetic neuralgia . Evidence level A
|Empirical Antimicrobial Treatment|
The principal goals of treatment of herpes zoster are reduction of pain in immunocompetent patients and inhibition of viral replication in immunocompromised patients.
Oral antiviral agents
The results of meta-analysis [8-10] and many - but not all - randomized control trials have demonstrated that antiviral therapy significantly reduces the incidence and duration of prolonged pain. Evidence level A
Aciclovir the first antiviral agent to be used, was studied in four clinical trials [11-15] and at a dose of 800mg 5 times daily started within 72 hours of the rash was shown to reduce the severity and duration of acute pain. Two clinical trials were conducted to compare Famciclovir to placebo, [16, 17] and a single clinical trial of two different doses of valaciclovir compared with aciclovir.  These showed famciclovir and valaciclovir to be effective in accelerating the resolution of post herpetic neuralgia. Evidence level A
There is some but no definite evidence that Famciclovir and valaciclovir may be more effective than Aciclovir , particularly with respect to speed of pain resolution. [18-20] These agents provide higher antiviral activity in blood and may promote patient adherence because they are dosed three rather than five times daily. Evidence level C
There is no clinical trial evidence available on starting antiviral treatment more than 72 hours after the onset of rash. However it may be beneficial in patients who have new vesicle formation, suggesting on-going viral replication, and in those patients with complications. Since the risks of treatment with antiviral drugs is minimal, it is recommended to consider treatment in patients with new vesicle formation more than 72 hours after onset of rash and in patients with neurological or ocular complications. Evidence level C
Recommendation: (Immunocompetent patients)
Treat with oral Aciclovir 800mg five times a day
Neurological or ocular complications:
Treatment duration is 7 days but longer courses may be required with ocular or neurological complications
Initial clinical trials of IV aciclovir in immunocompromised patients showed that treatment halts disease progression and reduces the duration of viral replication.  Subsequent trials showed that IV aciclovir is also effective at preventing virus dissemination. [22,23]
The dose should be calculated on ideal body weight to avoid over dosage of obese patients and is reduced in renal impairment (creatinine clearance <50ml /minute). When infection is controlled, i.e. the patient is systemically well and no new vesicles have appeared for 24 hours, then oral medication can be substituted for the duration of the course. There is limited clinical trial data on the use of Famciclovir and valaciclovir in immunocompromised patients, but growing clinical experience suggests that these medications are safe and effective in this setting. [24,25]
For patients who are less severely immunosuppressed, oral antiviral therapy with close observation is a reasonable option. The higher plasma concentrations of Famciclovir and valaciclovir along with simpler dose regime favours their use over oral aciclovir.
Recommendation (immunocompromised patients):
Please contact microbiology if the patient is not responding to the recommended antimicrobial regimens.
To improve the diagnosis and management of herpes zoster virus (HZ) infection in adults
|Target patient group:||Adults with suspected herpes zoster infection (shingles)|
|Target professional group(s):||Secondary Care Doctors
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- Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med 1994; 330:896–900
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- Dworkin RH, Boon RJ, Griffin DR, Phung D. Postherpetic neuralgia: impact of Famciclovir, age, rash severity and acute pain in herpes zoster patients. J Infect Dis 1998; 178(Suppl 1):S76–80.
- Beutner KR, Friedman DJ, Forszpaniak C, Andersen PL, Wood MJ. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother 1995; 39:1546–53.
- Degreef H. Famciclovir, a new oral antiherpes drug: results of the first controlled clinical study demonstrating its efficacy and safety in the treatment of uncomplicated herpes zoster in immunocompetent patients. Int J Antimicrob Agents 1994; 4:241–6.
- Shafran SD, Tyring SK, Ashton R, Decroix J, Forszpaniak C, Wade A, Paulet C, Candaele D. Once, twice, or three times daily famciclovir compared with aciclovir for the oral treatment of herpes zoster in immunocompetent adults: a randomized, multicenter, double-blind clinical trial. J Clin Virol. 2004;29(4):248
- Serota FT, Starr SE, Bryan CK, Koch PA, Plotkin SA, August CS. Acyclovir treatment of herpes zoster infections use in children undergoing bone marrow transplant. JAMA 1982; 247:2132–6.
- Shepp DH, Dandliker PS, Meyers JD. Treatment of varicella-zoster infection in severely immunocompromised patients: a randomized comparison of acyclovir and vidarabine. N Engl J Med 1986; 314:208–12.
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- Public Health England. The Green Book: Chapter 28a Shingles (herpes zoster). February 2016
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
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