Is prednisone used to treat shingles?

Treatment of Shingles with Prednisone

Prednisone should not be used as a primary treatment for shingles but can be used as an adjunctive therapy to antiviral medications in select cases to reduce acute pain and inflammation.

Primary Treatment Approach for Shingles

1. First-line therapy: Antiviral medications

   • Acyclovir (800 mg 5 times daily for 7 days)
   • Valacyclovir (1000 mg 3 times daily for 7 days)
   • Famciclovir (500 mg 3 times daily for 7 days)
   • Most effective when started within 72 hours of rash onset 1, 2

2. Role of prednisone in shingles treatment

   • Adjunctive therapy only - never as monotherapy
   • Used to reduce acute inflammation and pain
   • Short-term course (typically 3 weeks with tapering dose)
   • Starting dose typically 40 mg daily with gradual taper 3

Evidence for Prednisone Use in Shingles

Research shows that adding prednisone to antiviral therapy provides:

• Modest benefits in reducing acute pain during the initial phase of herpes zoster 1
• Slightly faster healing of rash (significant difference on days 7 and 14) 3
• No significant reduction in the incidence or duration of postherpetic neuralgia 3

Patient Selection for Prednisone Therapy

Consider adding prednisone for patients with:

• Severe acute pain
• Extensive rash
• No contraindications to corticosteroid use
• Age >50 years with moderate to severe symptoms

Avoid prednisone in patients with:

• Immunocompromised status
• Uncontrolled diabetes
• Active infections
• History of osteoporosis
• Contraindications to steroid therapy

Important Considerations and Precautions

1. Timing matters:

   • Both antivirals and prednisone should be started as soon as possible
   • Benefits diminish significantly if started >72 hours after rash onset

2. Monitoring required:

   • Blood glucose levels in diabetic patients
   • Blood pressure
   • Signs of secondary infection

3. Potential adverse effects:

   • Increased risk of infection
   • Hyperglycemia
   • Hypertension
   • Mood changes
   • Insomnia
   • Gastric irritation

4. Bone health considerations:

   • For patients taking ≥20 mg prednisone for ≥4 weeks, consider Pneumocystis prophylaxis 4
   • For postmenopausal women, men >50 years, or those at risk of fragility fracture taking ≥7.5 mg prednisone for ≥3 months, consider calcium and vitamin D supplementation and possibly bisphosphonates 4

Special Populations

1. Immunocompromised patients:

   • Avoid prednisone
   • Focus on antiviral therapy, possibly at higher doses or longer duration

2. Patients with ocular involvement (herpes zoster ophthalmicus):

   • Refer to ophthalmologist
   • Antiviral therapy is essential
   • Prednisone use should be guided by ophthalmology consultation 2

3. Pediatric patients with shingles:

   • Prednisone can be used for acute, widespread flares 4
   • Dose should be adjusted based on weight

Conclusion

While prednisone can provide modest benefits in reducing acute pain and inflammation in herpes zoster when combined with antiviral therapy, it does not prevent postherpetic neuralgia and carries potential risks. The decision to use prednisone should be based on the severity of symptoms, patient's age, and absence of contraindications to corticosteroid therapy.