Can capsaicin be used to treat shingles on the head?

Capsaicin for Shingles on the Head

Capsaicin should NOT be used during acute shingles but can be considered as a treatment option specifically for postherpetic neuralgia (pain persisting ≥90 days after rash onset) affecting the head, though it requires extreme caution due to the risk of ocular exposure and significant side effects. 1

Acute Shingles Treatment (First Priority)

For active shingles on the head, oral antiviral therapy is the standard of care and must be initiated immediately:

• Valacyclovir 1000 mg three times daily for 7 days is the preferred first-line treatment 2, 3
• Alternative: Acyclovir 800 mg five times daily for 7 days 2, 4
• Treatment should continue until all lesions have completely scabbed 2
• Initiate antivirals as soon as possible after rash onset, ideally within 72 hours, though later treatment may still provide benefit 3

Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 2

Capsaicin for Postherpetic Neuralgia (After Acute Phase)

Capsaicin becomes relevant only after the acute infection has resolved and persistent pain (postherpetic neuralgia) develops:

Evidence for Capsaicin Use

• Topical capsaicin is recommended for postherpetic neuralgia treatment alongside lidocaine, gabapentin, pregabalin, or tricyclic antidepressants 1
• A small study of 6 patients with herpes zoster ophthalmicus neuralgia showed marked pain relief in 4 patients when capsaicin was applied to the affected dermatome five times daily for 4 weeks 5
• Capsaicin works by depleting substance P, which inhibits pain transmission 5

Critical Safety Concerns for Head/Face Application

Capsaicin use on the head carries substantial risks that must be carefully weighed:

• Burning sensation at application site occurred in all 4 responders in the ophthalmicus study 5
• Dermatitis from overuse occurred in 2 of 6 patients 5
• Hyperesthesia developed in 1 patient 5
• Extreme caution is required near the eyes due to risk of severe ocular irritation if capsaicin contacts the eye surface

Clinical Algorithm for Capsaicin Consideration

Use capsaicin for head shingles ONLY if:

1. The acute infection has completely resolved (all lesions scabbed and healed) 2
2. Pain persists for ≥90 days (meeting criteria for postherpetic neuralgia) 1
3. The affected area is NOT periocular or at risk of eye contamination
4. First-line oral medications (gabapentin, pregabalin, tricyclic antidepressants) have been tried 1
5. The patient understands and accepts the high risk of burning and skin irritation 5

Application protocol if used:

• Apply topically to affected dermatome 5 times daily 5
• Duration: 4 weeks minimum 5
• Monitor closely for dermatitis and discontinue if severe irritation develops 5

Common Pitfalls to Avoid

• Never apply capsaicin during active shingles - it will not treat the viral infection and will cause severe burning on inflamed skin
• Never use capsaicin as monotherapy - always ensure antiviral treatment was given during acute phase 2
• Avoid periocular application - risk of severe ocular complications outweighs potential benefits for facial involvement
• Do not confuse acute pain management with postherpetic neuralgia treatment - these require different therapeutic approaches 1

Prevention Considerations

• Recombinant zoster vaccine (Shingrix) is strongly recommended for adults ≥50 years to prevent future episodes 6, 2
• Vaccination should be considered even after recovery from shingles 2