What is the safest treatment approach for a patient with unresolved shingles, currently on acyclovir (antiviral) 800 mg, medrol (methylprednisolone) dose pack, and triamcinolone (corticosteroid), who also receives infusion therapy for psoriatic arthritis?

Management of Unresolved Shingles in a Patient on Immunosuppression for Psoriatic Arthritis

The biologic infusion for psoriatic arthritis should be temporarily held until the shingles infection has completely resolved, and the current antiviral therapy should be optimized by switching from acyclovir to valacyclovir for improved bioavailability and pain control. 1, 2

Immediate Management of Active Shingles

Antiviral Optimization

• Switch from acyclovir 800 mg five times daily to valacyclovir 1,000 mg three times daily for the remainder of treatment, as valacyclovir provides three- to fivefold increases in acyclovir bioavailability and significantly accelerates resolution of herpes zoster-associated pain (median 38 days versus 51 days with acyclovir) 2
• Continue antiviral therapy for the full 7-10 day course from initiation, ensuring treatment was started within 72 hours of rash onset for maximum efficacy 1
• Monitor for neurologic symptoms including aggressive behavior, agitation, confusion, hallucinations, or seizures, particularly given the patient's immunosuppressed state and corticosteroid use 1

Corticosteroid Management

• The medrol dose pack and triamcinolone should be tapered and discontinued as soon as clinically feasible rather than continued chronically, as systemic corticosteroids are not recommended for chronic use in psoriatic disease due to risk of post-steroid psoriasis flare 3
• Short-term corticosteroid use for acute symptom control is acceptable, but prolonged use increases infection risk and may impair viral clearance 4

Biologic Therapy Safety Considerations

Holding Biologic Infusions

• Temporarily discontinue the biologic infusion until shingles has completely resolved (all lesions crusted over and no new lesion formation), as continuing immunosuppression during active varicella-zoster infection significantly increases risk of dissemination and complications 3
• The 2018 ACR/NPF guidelines conditionally recommend considering abatacept or alternative agents in patients with recurrent or serious infections, which applies to this clinical scenario 3

Specific Biologic Considerations

• If the patient is on a TNF inhibitor (infliximab, adalimumab, etanercept), this should be held during active infection as TNF inhibitors increase risk of serious infections including herpes zoster reactivation 3, 5
• If the patient is on an IL-17 inhibitor (secukinumab, ixekizumab), this should also be held as IL-17 inhibitors may increase risk of recurrent Candida infections and potentially other opportunistic infections 3
• If the patient is on an IL-12/23 inhibitor (ustekinumab), this carries relatively lower infection risk but should still be held during active viral infection 3

Resumption of Psoriatic Arthritis Treatment

Timing of Biologic Restart

• Resume biologic therapy only after complete resolution of shingles, defined as all lesions fully crusted and healed with no new lesion formation for at least 7 days 1
• Ensure the patient is no longer experiencing constitutional symptoms (fever, malaise) before restarting immunosuppression 1

Long-term Infection Risk Mitigation

• Consider switching to abatacept rather than resuming the current biologic if this represents a recurrent or serious infection, as the ACR/NPF guidelines conditionally recommend abatacept in patients with recurrent or serious infections 3
• Alternative consideration: IL-12/23 inhibitor (ustekinumab) may be preferred over TNF or IL-17 inhibitors in patients with history of serious infections, though this is a conditional recommendation based on low-quality evidence 3
• If severe psoriasis is present and infection risk is a concern, IL-12/23 inhibitors offer less frequent dosing (every 12 weeks after loading) which may reduce cumulative immunosuppression exposure 3, 5

Monitoring and Prevention

Ongoing Surveillance

• Monitor for postherpetic neuralgia development, which occurs in 19-26% of patients despite antiviral therapy and may persist for 6 months or longer 2
• Assess for signs of disseminated zoster (lesions beyond single dermatome, visceral involvement, neurologic complications) which would require hospitalization and intravenous acyclovir 1
• Document complete resolution of infection before any immunosuppressive therapy is restarted, including detailed skin examination and symptom assessment 1

Future Prevention

• Consider varicella-zoster vaccination (Shingrix) once the acute infection has resolved and before resuming biologic therapy, though live vaccines are contraindicated once immunosuppression is restarted 6
• Educate the patient to hold biologic infusions and contact their provider immediately if signs of infection develop in the future 6

Critical Pitfalls to Avoid

• Do not continue biologic infusions during active shingles, as this dramatically increases risk of dissemination, visceral involvement, and mortality in immunosuppressed patients 3
• Do not use systemic corticosteroids chronically for psoriatic arthritis management, as this increases infection risk and may cause rebound psoriasis flare upon withdrawal 3, 4
• Do not restart biologics prematurely before complete lesion crusting and healing, as residual viral replication may lead to recurrence or complications 1
• Do not assume standard acyclovir dosing is adequate—valacyclovir provides superior pain control and may be necessary in immunosuppressed patients 2