What is the prophylaxis for disseminated herpes zoster?

From the Guidelines

Prophylaxis for disseminated herpes zoster should be initiated with intravenous acyclovir 10 mg/kg every 8 hours, as it is the recommended treatment for complicated HZ, including disseminated cases, according to the most recent guidelines 1.

Key Considerations

• The treatment should be started within 72 hours of rash onset and continued for a minimum of 7-10 days 1.
• For patients who can take oral medications, oral valacyclovir or famciclovir in higher doses may be considered, but intravenous acyclovir is preferred for severe cases 1.
• Immunocompromised patients, including those with HIV/AIDS, organ transplant recipients, patients on immunosuppressive therapy, or those undergoing chemotherapy, are at high risk of disseminated disease and should be closely monitored 1.

Patient-Specific Factors

• The decision to start prophylaxis should be made on a case-by-case basis, considering the severity of the disease and the patient's immune status 1.
• Patients with a history of repeated antiviral therapy for recurrent disease should be monitored for acyclovir resistance 1.
• Antiviral prophylaxis against HSV is also advised during the period of neutropenia in patients who are HSV-seropositive and receiving chemotherapy, with acyclovir, valacyclovir, or famciclovir as the initial agents of choice 1.

From the Research

Prophylaxis for Disseminated Herpes Zoster

• The management of herpes zoster in immunocompromised patients involves reducing the incidence of cutaneous and visceral dissemination, which can lead to life-threatening complications 2.
• Prompt antiviral therapy is recommended for all immunosuppressed zoster patients if presentation occurs within 1 week of rash onset or any time before full crusting of lesions 2.
• For prophylaxis of herpesvirus infections in immunocompetent and immunocompromised older patients, aciclovir 400mg twice daily can prevent the recurrence of HSV eye disease 3.
• The varicella vaccine is an option for preventing herpes zoster disease, and its effectiveness will be tested in clinical trials 3.
• In immunocompromised patients, restoring immunity prevents herpesvirus disease, and specific antiviral therapy during the initial period after transplantation can prevent reactivation of HSV or CMV 3.

Treatment Guidelines

• For atypical disseminated herpes zoster in immunocompromised patients, timely diagnosis and initiation of antiviral therapy are crucial 4.
• Clinician awareness of methods for prevention and treatment of VZV infection in immunocompromised individuals is critical to minimize the risk for disease and associated morbidity 4.
• Valaciclovir or famciclovir should be preferred treatment options in patients with herpes zoster as they both provide significant reduction in risk of herpes-zoster-associated pain 5.
• The choice of antiviral therapy depends on the patient's immune status, with intravenous aciclovir therapy reserved for those with disseminated varicella zoster virus infection, ophthalmic involvement, very severe immunosuppression, or the inability to take oral medications 2.

Antiviral Therapy

• The efficacy and safety of different doses of antiviral agents in the treatment of herpes zoster have been evaluated in a meta-analysis, which found that 800 mg acyclovir with five times a day, 900-1 000 mg valaciclovir with three times a day, and 250 mg famciclovir with three times a day are better choices in the treatment of herpes zoster 6.
• Foscarnet is the drug of choice to treat aciclovir-resistant herpes zoster 2.
• Appropriate analgesic therapy should be combined with early antiviral treatment to reduce the incidence and severity of acute zoster pain and post-herpetic neuralgia 2.