What is the best treatment approach for an 85-year-old man with a shingles breakout in the left neck, arm, and wrist, who is on long-term steroid treatment?

Treatment for Shingles in an 85-Year-Old Man on Long-Term Steroid Treatment

Immediate antiviral therapy with valacyclovir 1 gram three times daily for 7 days is the recommended first-line treatment for this elderly immunocompromised patient with herpes zoster. 1

Initial Management

Antiviral Therapy

• Start valacyclovir 1 gram three times daily for 7 days
  • Initiate as soon as possible, ideally within 48 hours of rash onset 1
  • Valacyclovir is preferred over acyclovir due to better bioavailability and less frequent dosing (3 times daily vs 5 times daily) 2
  • Even if beyond 72 hours, antiviral therapy may still provide benefit in reducing pain duration 2

Pain Management

• For acute pain control:
  • Start with acetaminophen or NSAIDs if not contraindicated
  • Add gabapentin or pregabalin for neuropathic pain component
  • Consider short-term opioid analgesics if pain is severe

Steroid Management

• Continue current steroid treatment without interruption
• Do not increase steroid dose for herpes zoster management
• Adding additional corticosteroids specifically for zoster management provides only slight benefits over standard antiviral therapy alone 3

Special Considerations for This Patient

Immunocompromised Status

• Long-term steroid use increases risk of:
  • More severe herpes zoster infection
  • Higher risk of dissemination
  • Greater likelihood of post-herpetic neuralgia (PHN)
  • Potential for prolonged viral shedding

Age-Related Factors

• At 85 years old, this patient has:
  • Higher risk of developing PHN
  • Potentially more severe acute pain
  • May require longer treatment duration for symptom resolution

Monitoring and Follow-up

Short-term Monitoring (1-2 weeks)

• Assess for:
  • Resolution of skin lesions
  • Adequate pain control
  • Signs of bacterial superinfection (increasing erythema, purulence, fever)
  • Dissemination of infection (new lesions outside initial dermatome)

Long-term Monitoring (1-6 months)

• Evaluate for development of PHN
• If PHN develops, consider:
  • Continued neuropathic pain medications (gabapentin, pregabalin)
  • Tricyclic antidepressants (amitriptyline, nortriptyline)
  • Topical lidocaine patches
  • Thoracic transforaminal epidural steroid injections for refractory cases 4

Prevention of Future Episodes

• Consider zoster vaccination once current episode resolves
• The recombinant zoster vaccine (non-live) is recommended for immunocompromised adults 19 years and older 5

Potential Complications to Monitor

• Secondary bacterial skin infection
• Ocular involvement if lesions extend to face/forehead
• Disseminated zoster
• Post-herpetic neuralgia
• Neurological complications (motor neuropathy, cranial nerve palsies)

Key Pitfalls to Avoid

1. Delaying antiviral therapy - treatment should begin immediately, even if beyond 72-hour window
2. Discontinuing long-term steroid therapy during zoster episode
3. Inadequate pain management leading to increased risk of PHN
4. Failure to recognize bacterial superinfection requiring antibiotics
5. Overlooking potential ocular involvement requiring ophthalmologic evaluation

Valacyclovir has demonstrated excellent safety profile even with long-term use, making it appropriate for elderly patients 6. The recommended 7-day course is sufficient, as extending to 14 or 21 days has not shown significant additional benefits 2, 3.