Steroids in Herpes Zoster Management
Steroids can be given to patients with herpes zoster, but they provide only modest benefits for acute pain while offering no benefit for preventing postherpetic neuralgia, and should be used with caution in immunocompromised patients.
Evidence-Based Recommendations
Indications for Steroid Use
- Steroids may provide modest benefits in reducing acute pain and improving quality of life during the acute phase of herpes zoster
- Steroids do not prevent postherpetic neuralgia (PHN), which is the most concerning long-term complication 1
- Steroids should always be given with concurrent antiviral therapy, never alone
Patient Selection
Steroids should be limited to:
- Immunocompetent patients
- Patients without contraindications to steroids (diabetes, hypertension, psychiatric disorders)
- Patients with moderate to severe acute pain
- Patients receiving concurrent antiviral therapy
Contraindications
Avoid steroids in patients with:
- Immunocompromised status
- Uncontrolled diabetes mellitus
- Uncontrolled hypertension
- Active psychiatric disorders
- Patients receiving certain immunomodulatory therapies
Special Considerations
Immunocompromised Patients
For patients on immunomodulatory therapies or with immunocompromised status:
- Prophylaxis against herpes zoster is recommended for patients on bortezomib-based regimens 2
- Prophylactic antiviral therapy is recommended for all patients receiving protease inhibitor-based and antibody-based therapies 2
- Herpes zoster prophylaxis is important with bortezomib and steroid combinations 2
Vaccination Strategies
- Recombinant zoster vaccination (Shingrix) should be considered in all patients aged 50 or over receiving any immunomodulators or advanced therapies 2
- Patients aged 18 and over starting JAK inhibitors should receive recombinant zoster vaccination 2
- Herpes zoster vaccination may be considered in patients with autoimmune inflammatory rheumatic diseases, but only when less severely immunosuppressed 2
Treatment Protocol
Recommended Regimen
If steroids are used:
- Prednisone 40-60 mg/day tapered over 3 weeks 3, 4
- Must be combined with antiviral therapy (acyclovir 800 mg orally, five times daily for 7 days) 3
- Initiate within 72 hours of rash onset for maximum benefit 5
Monitoring
- Monitor for steroid-related adverse effects including:
- Hyperglycemia
- Hypertension
- Mood changes
- Secondary infections
- Skin atrophy
- Evaluate patients for development of bortezomib-related peripheral or autonomic neuropathy if applicable 2
Clinical Pearls and Pitfalls
Pearls
- Early initiation of antivirals (within 72 hours of onset) is more important than steroids for reducing severity and duration of herpes zoster 5
- Consider early initiation of anticonvulsants or tricyclic antidepressants in patients with high risk of postherpetic neuralgia 5
Pitfalls
- Relying on steroids to prevent postherpetic neuralgia (they don't work for this purpose)
- Using steroids without concurrent antiviral therapy
- Using steroids in immunocompromised patients, which may increase risk of disseminated disease 4
- Failing to recognize that JAK inhibitors may increase risk of herpes zoster (upadacitinib has shown increased rates of herpes zoster infection) 2
By following these evidence-based recommendations, clinicians can appropriately manage herpes zoster while minimizing risks associated with steroid therapy.