What are the dosing recommendations for prednisone in a patient with shingles already on valtrex (valacyclovir)?

Prednisone Dosing for Shingles in Patients Already on Valacyclovir

For a patient with shingles already on valacyclovir, prednisone 40 mg daily tapered over 3 weeks can be added as adjunctive therapy in select cases of severe or widespread disease, though it provides only modest additional benefit for acute pain without reducing postherpetic neuralgia risk. 1, 2

When to Consider Adding Prednisone

• The American Academy of Dermatology suggests prednisone may be used as adjunctive therapy to antivirals in select cases of severe, widespread shingles flares. 1

• Prednisone should generally be avoided in immunocompromised patients with shingles due to increased risk of disseminated infection. 1

• The Mayo Clinic emphasizes that prednisone use carries significant risks, particularly in elderly patients who are most susceptible to shingles. 1

Specific Dosing Protocol

• Initiate prednisone at 40 mg per day and taper over a 3-week period when adding to existing valacyclovir therapy. 2

• This regimen showed greater pain reduction during the acute phase (days 7-14) compared to antiviral monotherapy, though no difference in postherpetic neuralgia rates at follow-up. 2

• A significantly higher proportion of rash area healed on days 7 and 14 with steroid therapy compared to antiviral alone. 2

Critical Contraindications

Avoid prednisone in patients with:

• Poorly controlled diabetes 1
• History of steroid-induced psychosis 1
• Severe osteoporosis 1
• Prior severe steroid toxicity 1
• Immunocompromised status 1

Important Clinical Caveats

• The benefit of adding prednisone is modest and limited to the acute phase only—it does not reduce the frequency or duration of postherpetic neuralgia, which is the most important long-term outcome. 2

• Steroid recipients reported more adverse events in controlled trials. 2

• Continue valacyclovir until all lesions have scabbed, regardless of prednisone use—this is the key clinical endpoint, not an arbitrary duration. 1

• The standard valacyclovir dose is 1000 mg three times daily for 7 days, though treatment should extend beyond 7 days if lesions remain active. 1, 3

Practical Algorithm for Decision-Making

Add prednisone 40 mg daily (tapered over 3 weeks) only if:

1. Disease is severe or widespread 1
2. Patient is immunocompetent 1
3. No contraindications exist (diabetes, osteoporosis, psychosis history) 1
4. Patient understands the modest benefit is limited to acute pain reduction 2
5. Close monitoring for adverse effects is feasible 2

Do not add prednisone if:

1. Disease is mild or localized 1
2. Patient is immunocompromised 1
3. Any absolute contraindications present 1
4. Patient is elderly with multiple comorbidities 1