Are steroids recommended for the treatment of acute shingles?

Steroids for Acute Shingles Treatment

Steroids are recommended as an adjunctive treatment option for acute shingles, particularly for intralesional administration in carefully selected lesions during the acute phase. 1

Evidence-Based Recommendations

The evidence regarding steroid use in acute shingles presents a nuanced picture:

• Intralesional steroids: Guidelines from the North American Clinical Management Guidelines for Hidradenitis Suppurativa recommend considering intralesional corticosteroid injections for carefully selected individual lesions during the acute phase 1. This approach targets specific lesions rather than systemic administration.

• Systemic steroids: Research evidence shows that adding systemic steroids (prednisolone) to antiviral therapy provides only modest benefits in reducing acute pain during herpes zoster but does not reduce the frequency of postherpetic neuralgia 2. The benefits are slight compared to standard antiviral therapy alone.

Treatment Algorithm for Acute Shingles

1. First-line therapy:

   • Antiviral medication (acyclovir, famciclovir, or valacyclovir) started within 72 hours of rash onset 3

2. Adjunctive therapy options:

   • For localized painful lesions: Consider intralesional corticosteroid injections 1
   • For severe acute pain: Short-term systemic corticosteroids may be considered as a bridge therapy 1

3. Pain management:

   • Analgesics for acute pain control
   • For persistent pain: Consider early introduction of tricyclic antidepressants or anticonvulsants 4

Important Considerations

• Timing matters: Antiviral medications are most effective when started within 72 hours after rash onset 3

• Risk vs. benefit: While steroids may provide modest pain relief during the acute phase, they don't prevent postherpetic neuralgia and may increase adverse events 2

• Special populations: Caution is warranted in patients with diabetes, hypertension, or glaucoma who may not tolerate systemic steroids well 5

Potential Pitfalls

• Overreliance on steroids: Don't use steroids as monotherapy; they should always be combined with appropriate antiviral treatment 2, 3

• Long-term steroid use: Avoid prolonged systemic corticosteroid therapy due to potential adverse effects 1

• Ocular involvement: Herpes zoster with eye involvement requires prompt referral to an ophthalmologist regardless of steroid use 3

The most recent evidence suggests that while steroids may provide some short-term benefits for pain relief during acute shingles, their effect on preventing long-term complications like postherpetic neuralgia is limited. Therefore, they should be used judiciously as part of a comprehensive treatment approach that prioritizes timely antiviral therapy.