What are the treatment options and potential complications for shingles (herpes zoster) in children?

Treatment Options and Complications of Shingles in Children

The preferred treatment for herpes zoster (shingles) in children is oral acyclovir at a dose of 20 mg/kg body weight (maximum 800 mg/dose) four times daily for 7-10 days or until no new lesions appear for 48 hours. 1

First-Line Treatment Options

• Acyclovir is the mainstay of therapy for pediatric shingles and should be initiated as soon as possible, ideally within 72 hours of rash onset 2
• For children with mild to moderate disease and normal immune function, oral acyclovir at 20 mg/kg body weight (maximum 800 mg/dose) four times daily for 7-10 days is recommended 1
• For older children who can receive adult dosing, alternative options include:
  • Valacyclovir (for those able to receive adult dosing): 1000 mg three times daily for 7 days 3, 4
  • Famciclovir (for those able to receive adult dosing): 500 mg three times daily for 7-10 days 1

Treatment in Special Circumstances

• For children with severe immunosuppression, intravenous acyclovir is recommended 1
• For patients not responding to acyclovir, foscarnet 40-60 mg/kg body weight IV per dose three times daily for 7-10 days can be used 1
• Some experts base IV acyclovir dosing in children older than 1 year on body surface area (500 mg/m²/dose IV every 8 hours) instead of body weight 1
• For children with renal impairment, acyclovir dosage should be adjusted according to creatinine clearance 2

Potential Complications of Shingles in Children

Acute Complications

• Post-herpetic neuralgia (PHN) - persistent pain after rash healing, though less common in children than adults 5, 6
• Secondary bacterial skin infections of vesicular lesions 3
• Disseminated disease, especially in immunocompromised patients 7

Ocular Complications

• Herpes zoster ophthalmicus requires prompt referral to an ophthalmologist 1, 3
• Potential ocular complications include:
  • Keratitis
  • Uveitis
  • Corneal scarring
  • Corneal vascularization
  • Secondary glaucoma 3
• For acute retinal necrosis: Acyclovir 10 mg/kg body weight IV three times daily for 10-14 days, followed by oral valacyclovir 1 g three times daily for 4-6 weeks (for children old enough to receive adult dose) or oral acyclovir 20 mg/kg body weight for 4-6 weeks 1

Neurological Complications

• Encephalitis (rare in immunocompetent children)
• Motor neuropathy leading to weakness
• Cranial nerve palsies 6

Management Considerations

• Early initiation of antiviral therapy (within 72 hours of rash onset) is crucial for optimal outcomes 2, 6
• Adequate hydration should be maintained during treatment 2
• Pain management may be necessary, especially for older children 6
• For herpes zoster ophthalmicus, involvement of an experienced ophthalmologist is strongly recommended 1, 3
• Monitor for adverse effects of antiviral medications, including nausea, headache, and potential nephrotoxicity 2, 8

Prevention

• For substantial exposure to varicella or shingles in susceptible children (no history of varicella or zoster, seronegative status, or lack of age-appropriate vaccination), varicella-zoster immune globulin (VariZIG) 125 IU per 10 kg (maximum 625 IU) IM within 96 hours after exposure is recommended 1
• If VariZIG is unavailable or more than 96 hours have passed since exposure, prophylaxis with acyclovir 20 mg/kg body weight (maximum 800 mg) per dose orally four times daily for 5-7 days can be considered 1