What are the recommendations for a patient diagnosed with herpes zoster (shingles) 4 weeks ago, treated with valacyclovir (valacyclovir), who still has a rash on the right abdomen that is pruritic (itchy) and painful?

From the Guidelines

For persistent shingles symptoms after 4 weeks despite valacyclovir treatment, I strongly recommend consulting a healthcare provider for evaluation of postherpetic neuralgia (PHN) and consideration of alternative antiviral therapy, as the current treatment may not be effective in immunocompromised hosts or in cases of antiviral resistance, as suggested by the 2014 Infectious Diseases Society of America guidelines 1.

The patient's symptoms of a rash on the right abdomen that is itchy and painful, 4 weeks after the initial diagnosis of shingles and treatment with valacyclovir, may indicate a complicated case of herpes zoster, which can occur in immunocompromised hosts or due to antiviral resistance. According to the guidelines, high-dose IV acyclovir remains the treatment of choice for VZV infections in compromised hosts, and oral acyclovir, famciclovir, and valacyclovir are beneficial for VZV infections in otherwise healthy hosts 1.

Key considerations for the patient's treatment include:

• Evaluation for postherpetic neuralgia (PHN) and alternative antiviral therapy
• Topical treatments for pain management, such as lidocaine 5% patches or capsaicin 8% patches
• Oral medications for pain management, including gabapentin, pregabalin, tricyclic antidepressants, or duloxetine
• Antihistamines or hydroxyzine for itching relief
• Calamine lotion or colloidal oatmeal baths to soothe the skin

It is essential to consult a healthcare provider to determine the best course of treatment for the patient's specific condition, taking into account the potential for antiviral resistance and the need for alternative therapies, as recommended by the 2014 Infectious Diseases Society of America guidelines 1.

From the FDA Drug Label

The recommended dosage of VALTREX for treatment of herpes zoster is 1 gram 3 times daily for 7 days Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of the onset of rash.

The patient has already completed the 7-day course of valacyclovir, and it has been 4 weeks since the diagnosis of shingles. The rash on the right abdomen that is itchy and painful may be a postherpetic neuralgia, a common complication of shingles.

• The FDA drug label does not provide specific recommendations for the treatment of postherpetic neuralgia.
• The patient should be advised to consult their healthcare provider for further evaluation and management of their symptoms 2.

From the Research

Current Situation

• The patient was diagnosed with shingles 4 weeks ago and took valacyclovir.
• The patient still has a rash on the right abdomen that is itchy and painful.

Possible Complications

• Postherpetic neuralgia (PHN) is a possible complication of shingles, characterized by persistent pain in a dermatomal distribution sustained for at least 90 days after acute herpes zoster 3, 4.
• PHN can be treated with topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic antidepressants 3, 4.

Treatment Options

• The patient's current symptoms may be managed with topical or oral medications, such as:
  • Topical lidocaine or capsaicin to relieve pain and itching 3, 4.
  • Oral gabapentin, pregabalin, or tricyclic antidepressants to control pain 5, 6, 3, 4.
• Opioids may also be considered, but their use is associated with an increased risk of dependence, abuse, and diversion 7.

Considerations

• The patient's age and medical history should be taken into account when selecting a treatment option 7.
• A multimodal approach to pain management, including non-pharmacologic therapies, may be beneficial in reducing the patient's reliance on opioids 7.
• The patient's response to treatment should be closely monitored, and adjustments made as necessary to optimize pain control and minimize side effects 5, 6, 3, 4.