Shingles (Herpes Zoster): Drug Therapy

Therapeutic targets

• Shortening the symptomatic phase
• Avoidance of complications

Therapy recommendations

• Antiviral therapy: as soon as possible: virostasis (antivirals/drugs that inhibit viral replication)Note: Antiviral therapy within 72 hours of vesicle breakdown also reduces the risk of postzoster neuralgia.First-line therapy:
  • Patients <50 years + limited findings on trunk and extremities: Antivirals (aciclovir, brivudine, valaciclovir, and famciclovir), oral therapy.
  • Zoster generalisatus, herpes encephalitis, zoster ophthalmicus or oticus and immunocompromised patients: systemic therapy (intravenous administration): aciclovir.
• Topical therapy:
  • Local therapy (topical therapy): lotio alba (liquid suspension containing zinc oxide and talc, among other substances).
  • Topical virustatics (ophthalmic ointment) for viral epithelial keratitis.
• Analgesia (pain relief) of neuropathic pain according to WHO grading scheme:
  • Non-opioid analgesic for low pain intensity: metamizole, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen.
  • Low-potency opioid analgesic for moderate pain intensity: e.g., tramadol + non-opioid analgesic.
  • High-potency opioid analgesic for severe pain intensity: e.g., morphine + non-opioid analgesic.
  • For neuropathic pain, additional therapy with gabapentin or pregabalin is recommended (in ascending doses)
  • Duration of therapy: acute zoster disease 2-4 weeks.

  Note: Approximately 10-50% of zoster patients have persistent pain symptoms, and postherpetic neuralgia (PHN; synonyms: postzoster neuropathy; postzoster neuralgia, PZN; see below “herpes zoster/consequential diseases) develops.

• Bacterial superinfection: antibiotics.
• Postherpetic neuralgia (PHN; synonyms: postzoster neuropathy; postzoster neuralgia, PZN); 90 days after the onset of the rash is said to be postherpetic neuralgia (PHN; nerve pain occurring in the area that was affected by shingles).
  • Pain management according to WHO staging scheme:
    • Non-opioid analgesic: e.g., acetylsalicylic acid (ASA), ibuprofen, diclofenac, and acetaminophen; metamizole, if necessary.
    • Low-potency opioid analgesic (e.g., tramadol, tilidine) + non-opioid analgesic.
    • High-potency opioid analgesic (eg, morphine, oxycodone) + non-opioid analgesic.
  • First-line therapy:
    • Calcium channel-modulating antiepileptic drugs gabapentin or pregabalin and / or – esp. for shooting pain – carbamazepine as a sodium channel-modulating antiepileptic drug (= pain therapy according to guidelines of the German Society of Neurology).Gabapentin relieves neuropathic pain better than a placebo – according to a Cochrane review – for the diagnoses of painful diabetic neuropathy and postherpetic neuralgia.
    • If necessary, tricyclic antidepressants (eg, amitriptyline), if necessary, selective serotonin (norepinephrine) reuptake inhibitors (SSRI/SNRI) such as duloxetine.
  • Topical (local) therapy: capsaicin high-dose (8%) patch; effect: selective defunctionalization of TRPV1-expressing nociceptive nerve fibers; thus leads to pain reliefNot approved for treatment of face and head. However, Gaul and Resch describe applications to the face and head as safe.
  • A protective vaccination (standard and indicated) against the varicella zoster virus (VZV) is available (= herpes zoster vaccination).

Further notes

• Wg. antivirals: Lethal interaction: brivudine and 5-fluoropyrimidines.

Measures in pregnancy

• VZV exposure in a pregnant woman with unknown immune status:
  • All unvaccinated pregnant women without a history of varicella within 3 days and a maximum of up to 10 days after exposure administration of varicella-zoster immunoglobulin (VZIG) in the case of negative or borderline anti-VZV IgG.Alternative to VZIG: Aciclovir in terms of exposure prophylaxis after the end of the 14th SSW.
  • Notification of the neonatologist to coordinate immunoglobulin administration and vaccination.
• Pregnant women with zoster pneumonitis (pneumonia; therapy with aciclovir: see above).