Management of Disseminated Herpes Zoster
For disseminated herpes zoster, initiate intravenous acyclovir 5-10 mg/kg every 8 hours immediately and continue treatment until clinical resolution is attained, then switch to oral therapy. 1, 2
Initial Treatment Approach
Intravenous acyclovir is the definitive treatment for disseminated herpes zoster and should be started without delay regardless of the 72-hour window that applies to uncomplicated cases. 1, 2 The dosing is weight-based at 5-10 mg/kg administered every 8 hours. 1
Treatment Duration and Transition
- Continue IV acyclovir for a minimum of 7-10 days and until clinical resolution is attained—meaning all lesions have scabbed and no new lesions are forming. 1, 2
- Once clinical improvement occurs, switch to oral antiviral therapy (valacyclovir 1 gram three times daily or acyclovir 800 mg five times daily) to complete the treatment course. 1
- If new lesions continue to form or healing is incomplete beyond 7 days, extend treatment duration accordingly. 1
Immunosuppression Management
Temporarily reduce or discontinue immunosuppressive medications in patients with disseminated herpes zoster. 1, 2 This is a critical component of management that directly impacts morbidity and mortality. 1
- Immunosuppression may be cautiously restarted only after the patient has commenced anti-VZV therapy and skin vesicles have completely resolved. 1
- Monitor closely for visceral dissemination and complications during this period. 1
Special Considerations for Immunocompromised Patients
All immunocompromised patients with herpes zoster require antiviral treatment regardless of timing of presentation—the 72-hour rule does not apply to this population. 1 High-dose IV acyclovir remains the treatment of choice for VZV infections in severely compromised hosts. 2
- Watch for signs of cutaneous and visceral dissemination, which necessitate continuation of IV therapy. 3, 4
- Immunocompromised patients may develop chronic ulcerations with persistent viral replication and are at risk for secondary bacterial and fungal superinfections. 5
- Consider longer treatment duration if healing is delayed in this population. 1
Acyclovir-Resistant Disease
For suspected acyclovir-resistant herpes zoster (typically in severely immunocompromised patients with prior acyclovir exposure), switch to foscarnet 40 mg/kg IV every 8 hours. 1 Note that acyclovir-resistant isolates are routinely resistant to ganciclovir as well. 1
Common Pitfalls to Avoid
- Do not use oral antivirals for disseminated disease—IV therapy is mandatory for initial management to reduce life-threatening complications. 1, 2, 3
- Do not continue immunosuppression at full doses—this significantly increases mortality risk from visceral dissemination. 1
- Do not stop treatment at 7 days if lesions are still forming—treatment must continue until clinical resolution. 1
- Topical antiviral therapy is substantially less effective than systemic therapy and should not be used. 2