Adjunct Treatments for Shingles Beyond Valacyclovir
For most patients with shingles, valacyclovir alone is sufficient, but adjunct therapies include pain management, corticosteroids in select severe cases, skin care measures, and post-recovery vaccination with Shingrix.
Pain Management
Pain control is a critical adjunct to antiviral therapy, as zoster-associated pain significantly impacts quality of life.
- Analgesics should be initiated based on pain severity, starting with acetaminophen or NSAIDs for mild pain, progressing to gabapentin or pregabalin for neuropathic pain, and considering opioids for severe acute pain 1
- Topical lidocaine patches or capsaicin cream may provide additional relief for localized pain once lesions have crusted 1
Corticosteroid Therapy (Highly Selective Use)
The role of corticosteroids remains controversial and should be approached with caution.
- The American Academy of Dermatology suggests prednisone may be used as adjunctive therapy to antivirals in select cases of severe, widespread shingles, but this carries significant risks, particularly in elderly patients who are most susceptible to shingles 1
- A landmark randomized trial found that adding prednisolone (40 mg daily, tapered over 3 weeks) to acyclovir provided only slight benefits during the acute phase with greater pain reduction on days 7 and 14, but no reduction in postherpetic neuralgia frequency 2
- Corticosteroids should generally be avoided in immunocompromised patients due to increased risk of disseminated infection 1
- Absolute contraindications include poorly controlled diabetes, history of steroid-induced psychosis, severe osteoporosis, or prior severe steroid toxicity 1
The evidence suggests corticosteroids offer minimal long-term benefit and should only be considered in immunocompetent patients with severe, widespread disease who have no contraindications.
Skin Care and Local Measures
Proper wound care accelerates healing and prevents secondary complications.
- Keep the skin well hydrated with emollients to avoid dryness and cracking, particularly important for facial zoster 1
- Elevation of the affected area promotes drainage of edema and inflammatory substances, especially recommended for facial involvement 1
- Patients should avoid contact with susceptible individuals until all lesions have crusted, as lesions remain contagious to those who have not had chickenpox 1
Vaccination After Recovery
Post-recovery vaccination is an important adjunct to prevent future episodes.
- The CDC recommends the recombinant zoster vaccine (Shingrix) for all adults aged 50 years and older, regardless of prior herpes zoster episodes 1
- Vaccination can be considered after recovery to prevent future episodes and should ideally occur before initiating any immunosuppressive therapies 1
Treatment Duration Considerations
- Antiviral therapy should continue until all lesions have scabbed, which is the key clinical endpoint, not an arbitrary 7-day duration 1
- Treatment duration may need to be extended beyond 7 days if lesions remain active 1
Special Populations Requiring Modified Adjunct Therapy
- Immunocompromised patients with disseminated or invasive disease require IV acyclovir with temporary reduction in immunosuppressive medications 1
- Facial zoster requires particular attention due to risk of cranial nerve complications, necessitating ophthalmologic evaluation if periorbital involvement is present 1
Common Pitfalls to Avoid
- Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 1
- Do not rely on corticosteroids to prevent postherpetic neuralgia, as high-quality evidence shows no benefit for this outcome 2
- Antiviral medications do not eradicate latent virus but help control symptoms and reduce complications 1