Hydrocortisone Cream Should NOT Be Used for Herpes Zoster
Do not apply hydrocortisone cream or any topical corticosteroid to herpes zoster lesions. Topical corticosteroids are not recommended for herpes zoster treatment and may theoretically worsen viral replication, particularly in immunocompromised patients 1, 2.
Why Topical Corticosteroids Are Contraindicated
Topical antiviral therapy (and by extension, topical corticosteroids) are substantially less effective than systemic therapy and are not recommended for herpes zoster 1.
Corticosteroids can potentially aggravate viral infections by suppressing local immune responses, which is particularly concerning with active herpes zoster 3.
In immunocompromised patients, corticosteroids may facilitate viral replication and worsen the infection if adequate antiviral coverage is not provided 1, 2.
What You Should Use Instead
The appropriate treatment for herpes zoster is systemic antiviral therapy, not topical preparations:
Oral valacyclovir 1 gram three times daily for 7-10 days is the preferred first-line treatment, initiated within 72 hours of rash onset 1.
Oral acyclovir 800 mg five times daily for 7-10 days is an alternative option, though it requires more frequent dosing 1.
Treatment should continue until all lesions have completely scabbed, not just for an arbitrary 7-day period 1.
Evidence on Corticosteroids in Herpes Zoster
Systemic corticosteroids (oral prednisone) have been studied but are NOT effective for preventing postherpetic neuralgia:
A Cochrane meta-analysis found that oral corticosteroids given during acute herpes zoster infection do not prevent postherpetic neuralgia at 6 months (RR 0.95; 95% CI 0.45-1.99) 4.
While systemic corticosteroids may provide some benefit for acute pain relief during the active phase, they do not alter long-term outcomes 4, 5.
Topical corticosteroids have even less rationale than systemic corticosteroids, as they provide no systemic anti-inflammatory effect while potentially suppressing local antiviral immunity 3.
Critical Caveats
The evidence showing potential benefit of corticosteroids is limited to herpes labialis (cold sores), NOT herpes zoster (shingles) 6. A combination of 5% acyclovir + 1% hydrocortisone showed modest benefit for UV-induced herpes labialis, but this does not translate to herpes zoster treatment 6.
Even for herpes labialis, the addition of hydrocortisone to acyclovir provides minimal to no additional benefit over acyclovir alone 3.
In immunocompromised patients with herpes zoster, corticosteroids are particularly concerning and should only be considered in specific circumstances (such as severe inflammatory complications) under specialist guidance with adequate antiviral coverage 2.
Appropriate Skin Care for Herpes Zoster
For symptomatic relief of herpes zoster lesions:
Keep the affected area clean and dry to prevent secondary bacterial infection 1.
Emollients may be used to prevent excessive dryness after lesions have crusted, but avoid applying any products to active vesicular lesions 7.
Elevation of the affected area (if on an extremity or face) may help reduce edema 1.
Focus treatment on systemic antivirals, not topical preparations 1.