What is the recommended treatment for herpes zoster in pregnancy?

Treatment of Herpes Zoster in Pregnancy

Oral acyclovir 800 mg five times daily for 7-10 days is the recommended first-line treatment for herpes zoster during pregnancy. 1

Rationale and Evidence

Herpes zoster (shingles) during pregnancy requires prompt treatment to reduce maternal symptoms, prevent complications, and minimize potential risks to the fetus. The treatment approach should prioritize both maternal and fetal safety while effectively managing the viral infection.

First-Line Treatment Options

• Acyclovir: The antiviral medication with the most reported experience in pregnancy and appears to be safe 2

  • Dosage: 800 mg orally 5 times daily until clinical resolution (typically 7-10 days) 1
  • Current registry findings do not indicate an increased risk for major birth defects after acyclovir treatment compared to the general population 2

• Valacyclovir: May be considered as an alternative, though with less pregnancy safety data

  • Prenatal exposure data for valacyclovir is more limited than for acyclovir 2
  • When used, the recommended dose is 1 gram orally 3 times daily for 7 days

Treatment Algorithm

1. For uncomplicated herpes zoster in pregnancy:

   • Begin acyclovir 800 mg orally 5 times daily within 72 hours of rash onset
   • Continue treatment until all lesions have scabbed or completely healed (typically 7-10 days)
   • Monitor for clinical improvement within 7 days

2. For severe or disseminated herpes zoster:

   • Hospitalization and IV acyclovir (10 mg/kg every 8 hours) is indicated 2
   • This is particularly important for life-threatening maternal infections such as disseminated disease, encephalitis, pneumonitis, or hepatitis

3. For patients with renal impairment:

   • Adjust dosage based on creatinine clearance 1:
     • CrCl >25 mL/min: 800 mg every 4 hours, 5 times daily
     • CrCl 10-25 mL/min: 800 mg every 8 hours
     • CrCl <10 mL/min: 800 mg every 12 hours

Pain Management

• Mild pain: Acetaminophen or NSAIDs (preferred over opioids during pregnancy)
• Moderate to severe pain: Consider adding gabapentin after consultation with obstetrician
• Topical options: Lidocaine patches may be used for localized pain 1

Important Considerations and Precautions

Timing of Treatment

• Treatment is most effective when started within 72 hours of rash onset
• Even if beyond 72 hours, treatment should still be initiated, especially if new vesicles are forming or if the patient is at high risk for complications

Monitoring and Follow-up

• Schedule follow-up within 7 days to assess treatment response
• Monitor for complete resolution of lesions and development of postherpetic neuralgia
• Evaluate for any signs of dissemination or complications

Prevention of Transmission

• Pregnant women susceptible to varicella-zoster virus (VZV) should avoid exposure to persons with chickenpox or shingles 2
• Cover lesions to prevent transmission to susceptible individuals
• Pregnant healthcare workers should avoid caring for patients with active VZV infection if they lack immunity

Special Considerations

Potential Complications

• Postherpetic neuralgia (PHN) is a significant concern and may require extended pain management
• Ophthalmic involvement requires urgent ophthalmologic consultation
• Disseminated disease may require hospitalization and IV therapy

Vaccination

• Live attenuated zoster vaccine is contraindicated during pregnancy
• Household contacts of pregnant women should be vaccinated if they have no history of chickenpox and are seronegative for HIV 2

By following this treatment approach, clinicians can effectively manage herpes zoster in pregnant patients while minimizing risks to both mother and fetus.