What is the role of steroids in managing an acute shingles (herpes zoster) flareup?

From the Guidelines

Steroids should not be used as the primary treatment for acute shingles flareups, but rather as an adjunct to antiviral therapy to reduce inflammation and pain, with careful consideration of potential side effects and contraindications. When managing an acute shingles flareup, the role of steroids is supportive, aiming to alleviate symptoms and potentially decrease the risk of postherpetic neuralgia.

• The use of steroids, such as prednisone, is typically considered for patients with moderate to severe pain, facial involvement, or those at higher risk for complications.
• It is crucial to initiate steroid therapy within 72 hours of rash onset for maximum effectiveness.
• Steroids work by suppressing the inflammatory response, which contributes to nerve damage during shingles outbreaks.
• Important precautions include avoiding steroids in immunocompromised patients, those with diabetes, or with contraindications to steroid therapy, as noted in general steroid management principles 1.
• Patients should always take the full course of antivirals (such as acyclovir, valacyclovir, or famciclovir) alongside steroids, as steroids alone may worsen outcomes by potentially increasing viral replication if not countered by antiviral medication.
• The dose and duration of steroid therapy, such as prednisone 40-60mg daily for 7-10 days with a gradual taper, should be carefully managed to minimize side effects and prevent rebound inflammation.
• Monitoring for and managing potential side effects of steroid therapy, such as steroid-induced diabetes mellitus, osteonecrosis, and gastrointestinal issues, is essential, as outlined in principles for steroid management 1.

From the Research

Role of Steroids in Managing Acute Shingles Flareup

• The use of steroids in managing an acute shingles (herpes zoster) flareup has been studied in several trials 2, 3.
• According to a study published in the American Family Physician, the addition of an orally administered corticosteroid can provide modest benefits in reducing the pain of herpes zoster and the incidence of postherpetic neuralgia 2.
• A randomized trial published in The New England Journal of Medicine found that treatment with acyclovir for 21 days or the addition of prednisolone to acyclovir therapy confers only slight benefits over standard 7-day treatment with acyclovir, but steroid therapy did reduce pain during the acute phase of the disease 3.
• However, the same study found that steroid recipients reported more adverse events, highlighting the need for careful consideration of the potential benefits and risks of steroid use in managing acute shingles 3.

Comparison with Antiviral Medications

• Antiviral medications such as acyclovir, valacyclovir, and famciclovir are the primary treatment for herpes zoster, and are most effective when started within 72 hours after the onset of the rash 2, 4, 5.
• A systematic review of high-quality randomized controlled trials found that valacyclovir and famciclovir are superior to acyclovir in reducing the risk of pain associated with herpes zoster, and should be preferred treatment options 4.
• The use of steroids as an adjunct to antiviral therapy may be considered in certain cases, but the evidence suggests that antiviral medications are the primary treatment for herpes zoster 2, 3, 4, 5.

Prevention and Management

• Prevention strategies, such as vaccinating those at greatest risk, may offer the best option for reducing the burden of herpes zoster on healthcare systems 6.
• Management of herpes zoster is focused on symptom control, and includes the use of antiviral medications, topical lidocaine or capsaicin, and oral gabapentin, pregabalin, or tricyclic antidepressants 5, 6.
• The use of steroids in managing acute shingles flareup should be carefully considered, taking into account the potential benefits and risks, and should be used in conjunction with antiviral medications and other symptom-control measures 2, 3.