Title: Herpes zoster = shingles = shingles
Source: uptodate 2023
A. Antiviral therapy:
* Give IV only in conditions of severe immunodeficiency or complications of shingles (acute retinal necrosis, encephalitis, etc.). PO the rest.
A1. Valacyclovir:
1. Valacyclovir 1000mg TDS.
A2. Famciclovir:
2. Famciclovir 500mg TDS.
A3. Acyclovir: a choice in pregnancy
3A. Acyclovir 800mg PO five times daily.
Give with the same dose during pregnancy.
3B. Acyclovir 10mg/kg IV q8h.
In immunocompromised patients with the possibility of spreading the disease
* Acyclovir requires renal dose adjustment.
* Indications of antiviral therapy:
1. Within the first 72 hours of symptoms
2. After the first 72 hours in immunocompromised people: organ transplantation, blood malignancies, chemotherapy, advanced AIDS infection with CD4 below 200, especially if they do not receive antiretroviral treatment, high dose corticosteroids (prednisolone above 20mg per day for more than 2 weeks), Treatment with immunomodulators (such as rituximab or TNF inhibitors), the risk of more damage in the involved dermatome (such as the risk of involvement of eye movements in case of V1 dermatome involvement), age over 65 years, new lesions after 72 hours
* If all lesions are crusted, antiviral therapy is useless.
b. Management of acute neuritis:
B1: Acetaminophen and NSAID: for all patients
B2: short-acting opioid analogs: oxycodone
B3. Corticosteroids: give opioids if unresponsive. Do not give to diabetics. According to some studies, in combination with acyclovir, it accelerates the recovery of the general condition and acute pain.
B2. 10-14 days tapering course of oral Prednisone starting at 40mg/day.
B4. Gabapentin: also given in PHN.
B5: Bupivacaine: considered as a nerve block
P. Management of postherpetic neuralgia (PHN): discussed in the next post.
T. Secondary bacterial infection: The AB regimen should cover both staph and strep.
Th. Treatment failure: Consider prescribing foscarnet.
c. Recurrent shingles: start antiviral therapy at the same initial dose. Suspect immunodeficiency, but do not do work-up unless you suspect a specific disease in the initial evaluation.
Ch. Complicated shingles:
Q1: Diffuse infection: it means the involvement of at least 2 dermatomes or on both sides of the body or the involvement of two non-adjacent dermatomes. These are almost always immune deficiencies.
* Acyclovir 10mg/kg IV q8h.
* when lesions are improving the patient can be transitioned to Valacyclovir 1g PO TDS for 10-14 days but may need to be extended in those with ongoing symptoms.
Ch2: HZO and acute retinal necrosis (ARN): there is a risk of blindness. Treat with an ophthalmologist.
Q3: Ramsay-Hunt syndrome:
* Valacyclovir 1g TDS for 7-10 days + Prednisone 1mg/kg for 5 days, without a taper.
* In severe cases such as dizziness, tinnitus, hearing loss, etc., give IV and when the lesions are crusted, give PO.
H. Neurological complications: for example, in conditions of symptomatic meningitis, encephalitis, myelitis, etc.
* Acyclovir 10mg/kg IV q8h for 10-14 days.
@PARASTAARAN