How to manage symptoms of Varicella-Zoster Virus (VZV) reactivation, also known as shingles?

Management of VZV Reactivation (Shingles)

The first-line treatment for shingles is antiviral therapy with valacyclovir 1000 mg three times daily for 7 days, famciclovir 500 mg three times daily for 7 days, or acyclovir 800 mg five times daily for 7 days, initiated within 72 hours of rash onset to reduce acute pain and prevent postherpetic neuralgia. 1

Clinical Presentation and Diagnosis

Herpes zoster (shingles) presents with distinctive characteristics:

• Unilateral vesicular eruption in a dermatomal distribution
• Prodromal pain that often precedes skin findings by 24-72 hours
• Progression from erythematous macules to papules, vesicles, pustules, and finally crusting
• Lesions typically continue to erupt for 4-6 days in immunocompetent hosts
• Complete disease duration of approximately 2 weeks in healthy individuals 2

Antiviral Treatment

Immunocompetent Patients

For immunocompetent adults with herpes zoster, initiate one of the following as soon as possible (ideally within 72 hours of rash onset):

• Valacyclovir: 1000 mg three times daily for 7 days 3
• Famciclovir: 500 mg every 8 hours for 7 days 4
• Acyclovir: 800 mg five times daily for 7 days 1

Immunocompromised Patients

For immunocompromised patients (including HIV-infected individuals):

• High-dose IV acyclovir is the treatment of choice 2
• Once clinical improvement occurs, transition to oral therapy to complete the treatment course 1
• Continue treatment until all lesions have crusted over 1

Pain Management

Shingles-associated pain requires a multi-modal approach:

1. First-line options:

   • Gabapentin (start at 300 mg once daily, titrate to 2400 mg/day in divided doses) 1
   • Acetaminophen or NSAIDs for mild pain

2. For moderate to severe pain:

   • Add pregabalin if gabapentin alone is insufficient 1
   • Consider tricyclic antidepressants (nortriptyline or desipramine) starting at low doses and titrating up to 50-75 mg 1

3. For refractory pain:

   • Capsaicin 8% patch (single 30-minute application) can provide relief for up to 12 weeks 1
   • Consider topical lidocaine patches for localized pain 5

Special Considerations

Ocular Involvement

If herpes zoster affects the ophthalmic branch of the trigeminal nerve:

• Urgent ophthalmology referral is required
• Evaluate for conjunctivitis, keratitis, uveitis/iritis, and secondary glaucoma 1
• Topical antivirals may be used as adjunctive treatment in unresponsive cases 1
• Use topical corticosteroids with caution, preferring those with poor ocular penetration 1

Postherpetic Neuralgia (PHN)

PHN is defined as pain persisting for at least 90 days after acute herpes zoster 6:

• Early antiviral therapy reduces the risk of developing PHN 1
• For established PHN, treatment focuses on symptom control with:
  • Gabapentin or pregabalin
  • Tricyclic antidepressants
  • Topical lidocaine or capsaicin
  • Opioids may be required for severe, refractory pain 5

Prevention

• Zoster vaccination is recommended for adults aged 60 years and older to prevent future outbreaks and complications 1
• Household contacts of immunocompromised persons should be vaccinated against VZV if they have no history of chickenpox and are seronegative for HIV 1

Common Pitfalls to Avoid

1. Delayed treatment: Initiating antiviral therapy beyond 72 hours of rash onset significantly reduces efficacy
2. Inadequate pain control: Pain from herpes zoster can be severe and debilitating, requiring aggressive multimodal management
3. Missing ocular involvement: Always evaluate for eye involvement, especially with rash in the V1 distribution
4. Underestimating immunocompromised patients' risk: These patients may develop more severe disease with atypical presentations, multidermatomal involvement, and higher complication rates 1
5. Inadequate treatment duration: Continue antivirals until all lesions have crusted over, which may take longer in immunocompromised patients 1

By following this evidence-based approach to managing VZV reactivation, clinicians can effectively reduce acute symptoms, prevent complications, and improve patients' quality of life.