What is the treatment for herpes zoster (shingles) in the ear?

Treatment of Herpes Zoster in the Ear (Ramsay Hunt Syndrome)

For herpes zoster affecting the ear (Ramsay Hunt syndrome), initiate oral valacyclovir 1 gram three times daily for 7 days combined with systemic corticosteroids, starting treatment as soon as possible and ideally within 72 hours of symptom onset. 1, 2, 3

Immediate Recognition and Treatment Initiation

Herpes zoster oticus (Ramsay Hunt syndrome) presents with vesicles on the external ear canal and posterior auricle, severe otalgia, facial paralysis or paresis, loss of taste on the anterior two-thirds of the tongue, and decreased lacrimation on the affected side. 1 This is a medical urgency requiring prompt systemic antiviral therapy and systemic steroids. 1

First-Line Antiviral Therapy

• Valacyclovir 1 gram orally three times daily for 7 days is the recommended first-line treatment. 2, 3
• Treatment must be initiated within 72 hours of rash onset when possible, though benefit may extend beyond this window. 2, 3
• Alternative option: Acyclovir 800 mg orally five times daily for 7 days if valacyclovir is unavailable. 2, 3
• Another alternative: Famciclovir 500 mg three times daily for 7 days offers comparable efficacy with more convenient dosing than acyclovir. 4, 5, 6

The FDA-approved dosing for herpes zoster is valacyclovir 1 gram three times daily for 7 days, initiated at the earliest sign or symptom and most effective when started within 48 hours of rash onset. 3

Role of Corticosteroids

Systemic corticosteroids should be added to antiviral therapy for Ramsay Hunt syndrome given the facial nerve involvement. 1 While a large trial showed that adding prednisolone (40 mg daily, tapered over 3 weeks) to acyclovir provided greater pain reduction during the acute phase but did not reduce postherpetic neuralgia, 7 the facial paralysis component of Ramsay Hunt syndrome warrants steroid use to potentially improve nerve recovery outcomes. 1

When to Escalate to Intravenous Therapy

• For severe disease, disseminated infection, or immunocompromised patients: Switch to intravenous acyclovir 5-10 mg/kg every 8 hours until clinical improvement occurs, then transition to oral therapy to complete the treatment course. 2
• Continue IV therapy until clinical resolution is attained, particularly if new lesions continue to form or healing is incomplete. 2
• Immunocompromised patients require antiviral treatment regardless of timing and may need temporary reduction or discontinuation of immunosuppressive medications in severe cases. 2

Treatment Duration and Monitoring

• Standard treatment duration is 7 days minimum, with continuation until clinical resolution if healing is delayed. 2, 3
• Monitor closely for complications including dissemination, visceral involvement, and progression of facial nerve dysfunction. 2
• In immunocompromised patients, consider longer treatment duration if healing is delayed. 2

Critical Pitfalls to Avoid

• Do not rely on topical antivirals for herpes zoster oticus—systemic therapy is mandatory. 1
• Do not delay treatment waiting for laboratory confirmation; diagnosis is clinical and treatment should begin immediately. 1
• Do not confuse with acute otitis externa—the presence of vesicles, facial paralysis, and severe pain distinguish Ramsay Hunt syndrome. 1
• Do not use acyclovir-resistant protocols initially—reserve foscarnet (40 mg/kg IV every 8 hours) only for documented acyclovir-resistant cases. 2

Comparative Efficacy of Antivirals

Valacyclovir demonstrates superior pain resolution compared to acyclovir, with median pain duration of 38 days versus 51 days for acyclovir in patients ≥50 years, while maintaining similar efficacy for cutaneous lesion resolution. 8 Famciclovir 500 mg three times daily shows comparable efficacy to both valacyclovir and acyclovir for acute lesion resolution and significantly reduces postherpetic neuralgia duration by approximately 56-100 days compared to placebo. 5, 6