What is the recommended treatment for an adult over 50 with shingles (herpes zoster) in the ear?

Treatment of Shingles in the Ear (Herpes Zoster Oticus)

For an adult over 50 with shingles affecting the ear, initiate oral valacyclovir 1000 mg three times daily or acyclovir 800 mg five times daily immediately, ideally within 72 hours of rash onset, and continue treatment until all lesions have completely scabbed—typically 7-10 days but potentially longer if new lesions continue to form. 1

Immediate Antiviral Therapy

The cornerstone of treatment is prompt systemic antiviral therapy:

• Valacyclovir 1000 mg three times daily for 7-10 days is the preferred first-line option due to superior bioavailability and less frequent dosing, which improves adherence 1, 2
• Acyclovir 800 mg five times daily for 7-10 days remains an effective alternative, though requires more frequent dosing 1, 3
• Famciclovir 500 mg three times daily for 7-10 days offers comparable efficacy with convenient dosing 1, 2

Treatment must be initiated within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia 1. However, even if the 72-hour window has passed, antiviral therapy should still be initiated as it may provide benefit, particularly in patients over 50 who are at higher risk for complications 4.

Critical Treatment Endpoint

Do not discontinue antiviral therapy at exactly 7 days if lesions are still forming or have not completely scabbed. 1 The key clinical endpoint is complete scabbing of all lesions, not an arbitrary calendar duration. Treatment should continue until this endpoint is reached, which may extend beyond 10 days in some patients 1.

Special Considerations for Ear Involvement

Shingles affecting the ear warrants heightened vigilance due to potential complications:

• Ramsay Hunt syndrome (herpes zoster oticus with facial nerve involvement) can occur, presenting with facial paralysis, ear pain, and vesicles in the ear canal or on the auricle 1
• Urgent evaluation is essential if there are signs of facial weakness, hearing loss, vertigo, or vesicles visible in the external auditory canal 2
• Facial zoster requires particular attention due to risk of cranial nerve complications 1

When to Escalate to Intravenous Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours if any of the following develop 1:

• Disseminated herpes zoster (lesions in more than 3 dermatomes or visceral involvement)
• Suspected CNS involvement (meningitis, encephalitis)
• Severe immunocompromise (active chemotherapy, HIV with low CD4 count, high-dose immunosuppression)
• Inability to take oral medications
• Failure to respond to oral therapy within 7-10 days

Continue IV therapy for at least 7-10 days and until clinical resolution is attained 1.

Adjunctive Management

Pain Control

• Acute neuritis may require analgesics ranging from acetaminophen/NSAIDs to opioids for severe pain 4
• Neuropathic pain agents (gabapentin, pregabalin, or tricyclic antidepressants in low doses) can be initiated early if pain is severe 4

Corticosteroids

• Oral corticosteroids may provide modest benefits in reducing acute pain but carry significant risks (infections, hypertension, osteopenia, hyperglycemia) that generally outweigh benefits in most patients 1, 4
• Avoid corticosteroids in immunocompromised patients as they can increase risk of disseminated infection 1

Skin Care

• Keep lesions clean and dry to prevent secondary bacterial infection 4
• Avoid applying topical corticosteroids to active vesicular lesions as they can worsen viral replication 1
• Emollients may be used after lesions have crusted to prevent excessive dryness 1

Monitoring and Follow-Up

• Monitor renal function if using acyclovir or valacyclovir, particularly in elderly patients or those with baseline renal impairment, as dose adjustments may be necessary 1, 5
• If lesions fail to begin resolving within 7-10 days despite appropriate therapy, suspect acyclovir resistance and consider viral culture with susceptibility testing 1
• For confirmed acyclovir resistance, switch to foscarnet 40 mg/kg IV every 8 hours until clinical resolution 1

Prevention of Future Episodes

All adults aged 50 years and older should receive the recombinant zoster vaccine (Shingrix) regardless of prior herpes zoster episodes. 6, 1 This vaccine:

• Reduces shingles incidence by approximately 90% even in the oldest age groups 1
• Requires two doses administered 2-6 months apart 6
• Is preferred over the older live attenuated vaccine (Zostavax) due to superior efficacy 6, 2
• Can be administered after recovery from the current episode to prevent recurrence 1

Common Pitfalls to Avoid

• Do not use topical antivirals as they are substantially less effective than systemic therapy 1, 4
• Do not stop treatment at exactly 7 days if lesions have not completely scabbed 1
• Do not delay treatment waiting for laboratory confirmation in typical presentations 4
• Do not use live attenuated zoster vaccine (Zostavax) in immunocompromised patients; use recombinant vaccine (Shingrix) instead 6, 1
• Do not apply topical corticosteroids to active vesicular lesions without concurrent systemic antiviral therapy 1, 2

Infection Control

Patients should avoid contact with susceptible individuals (pregnant women who are varicella-seronegative, immunocompromised persons, infants) until all lesions have crusted, as the virus can be transmitted and cause varicella in susceptible contacts 1.