Do steroids help with shingles?

Steroids for Shingles: Limited Benefit and Not Recommended

Corticosteroids are not recommended for the routine treatment of shingles (herpes zoster) as they do not prevent postherpetic neuralgia and provide only modest short-term benefits for pain relief.

Evidence on Corticosteroid Use in Shingles

The most recent and highest quality evidence from a 2023 Cochrane systematic review shows that corticosteroids given during acute herpes zoster infection have uncertain effects on preventing postherpetic neuralgia, the most debilitating complication of shingles 1.

Short-term Pain Relief

• Corticosteroids may provide modest benefits in reducing acute pain during the initial phase of herpes zoster
• Some studies showed greater pain reduction in the acute phase with steroid therapy 2
• However, these benefits are temporary and limited to the acute phase only

Postherpetic Neuralgia Prevention

• Multiple studies have consistently shown that corticosteroids do not reduce the incidence of postherpetic neuralgia
• The 2023 Cochrane review found no significant difference in postherpetic neuralgia at 6 months between corticosteroid and placebo groups (RR 0.95% CI 0.45 to 1.99) 1
• Earlier studies suggesting benefit (like the 1980 study comparing prednisolone to carbamazepine 3) have been superseded by more rigorous research

Safety Considerations

• While serious adverse events were not significantly different between corticosteroid and placebo groups in clinical trials 1, corticosteroids carry risks including:
  • Increased risk of infection
  • Hyperglycemia and hypertension in susceptible patients
  • Potential for adrenal suppression
  • Other systemic effects with prolonged use

Current Treatment Recommendations

First-line Treatment

• Antiviral medications (acyclovir, famciclovir, valacyclovir) started within 72 hours of rash onset 4
• These medications are most effective when initiated early

Pain Management

• Appropriate analgesics for acute pain control
• For postherpetic neuralgia:
  • Tricyclic antidepressants
  • Anticonvulsants
  • Topical agents (capsaicin, lidocaine patches)
  • Nerve blocks in selected patients

Special Considerations

• In immunocompromised patients, aggressive antiviral therapy is essential
• Ocular involvement requires prompt referral to an ophthalmologist 4

When Corticosteroids Might Be Considered

Despite the lack of evidence for preventing postherpetic neuralgia, short courses of corticosteroids might be considered in very limited circumstances:

• For severe, widespread acute flares with significant inflammation 5
• When pain is severe and debilitating in the acute phase
• In patients without contraindications to corticosteroid use

If used, corticosteroids should be:

• Limited to short courses (typically 7-14 days)
• Tapered appropriately
• Used in conjunction with antiviral therapy
• Avoided in patients with contraindications

Conclusion

The evidence does not support routine use of corticosteroids for shingles. Treatment should focus on early antiviral therapy and appropriate pain management. While corticosteroids may provide modest short-term pain relief, they do not prevent the development of postherpetic neuralgia and carry potential risks that outweigh their limited benefits in most patients.