Are steroids a treatment for shingles?

Steroids Are Not Recommended as Primary Treatment for Shingles

Steroids are not recommended as a primary treatment for shingles (herpes zoster), as they may potentially worsen outcomes by suppressing immune function and allowing for increased viral replication.

Understanding Shingles and Its Management

Shingles is caused by reactivation of the varicella-zoster virus (VZV) that becomes latent in cerebral or posterior root ganglia after primary infection (chickenpox). The reactivation typically occurs due to declining cellular immunity, often associated with aging, stress, or immunocompromised states 1.

Primary Treatment Approach for Shingles

The cornerstone of shingles treatment includes:

1. Antiviral Medications:

   • Oral acyclovir, famciclovir, or valacyclovir
   • Most effective when started within 72 hours of rash onset 2
   • These medications help reduce viral replication, accelerate healing, and may reduce acute pain

2. Pain Management:

   • Analgesics for acute pain control
   • May require stronger medications including narcotics in severe cases
   • Tricyclic antidepressants or anticonvulsants for neuropathic pain components 2

The Role of Steroids in Shingles Management

Corticosteroids have been studied in shingles treatment, but evidence does not support their routine use:

• Limited Efficacy: A Cochrane systematic review found very low-certainty evidence regarding the effectiveness of corticosteroids in preventing postherpetic neuralgia (PHN), a common complication of shingles 3

• Potential Risks:

  • Corticosteroids can suppress immune function, potentially allowing for increased viral replication
  • They may contribute to the development of shingles when used chronically 1
  • The risk-benefit ratio does not favor their routine use

• Limited Indications: Steroids might be considered in specific scenarios:

  • As adjunctive therapy to antivirals in severe cases with significant inflammation
  • For acute, widespread flares in certain inflammatory conditions 4
  • For carefully selected individual lesions during the acute phase 4

Special Considerations

Intralesional Steroid Injections

While not recommended as primary therapy for shingles, intralesional corticosteroid injections might be considered in very specific circumstances:

• For carefully selected, individual lesions during the acute inflammatory phase 4
• This approach should be used cautiously and is not a first-line treatment

Epidural Steroid Injections

For severe pain associated with acute-phase shingles, epidural steroid injections have been studied:

• Both interlaminar and transforaminal approaches have shown some efficacy for pain relief
• However, there was no significant difference between approaches in preventing postherpetic neuralgia 5
• This intervention should be reserved for cases with severe, refractory pain

Potential Complications and Monitoring

If steroids are used despite the general recommendation against them:

• Monitor for worsening infection or dissemination
• Watch for steroid-related adverse effects including hyperglycemia and hypertension
• Be vigilant for signs of secondary bacterial infection
• Consider the increased risk of prolonged viral shedding

Conclusion

For the management of shingles, the primary approach should focus on early antiviral therapy and appropriate pain management. Corticosteroids are not recommended as primary treatment for shingles due to concerns about immune suppression and potential for increased viral replication. The evidence for their benefit in preventing postherpetic neuralgia is of very low certainty, while the risks of immunosuppression are well-established.