From the Guidelines
Treatment for ophthalmic herpes zoster should begin with oral antiviral therapy as soon as possible, ideally within 72 hours of rash onset, with the recommended regimens including valacyclovir 1000 mg three times daily, famciclovir 500 mg three times daily, or acyclovir 800 mg five times daily, all for 7-10 days, as supported by the most recent evidence 1. The goal of treatment is to reduce viral replication, shorten the duration of symptoms, decrease the risk of post-herpetic neuralgia, and minimize ocular complications.
- Key considerations in managing ophthalmic herpes zoster include:
- Prompt initiation of oral antiviral therapy
- Pain management with acetaminophen, NSAIDs, or gabapentin/pregabalin for severe cases
- Topical steroids and cycloplegic agents for ocular involvement under ophthalmological supervision
- Monitoring for complications such as keratitis, uveitis, and increased intraocular pressure
- According to the guidelines, patients with severe cases or those who are immunocompromised may require intravenous acyclovir 10 mg/kg every 8 hours 1.
- The importance of early treatment and referral to an ophthalmologist for comprehensive evaluation and management of potential sight-threatening complications is emphasized in the literature 1.
- Prevention strategies, including vaccination against herpes zoster, are also crucial in reducing the incidence of ophthalmic herpes zoster, especially in individuals 50 years or older and those who are immunocompromised 1.
From the FDA Drug Label
The efficacy and safety of famciclovir tablets have not been established for: • Patients with first episode of genital herpes • Patients with ophthalmic zoster • Immunocompromised patients other than for the treatment of recurrent episodes of orolabial or genital herpes in HIV-infected patients • Black and African American patients with recurrent genital herpes
The FDA drug label does not answer the question.
From the Research
Ophthalmic Herpes Zoster Treatment
- The treatment of ophthalmic herpes zoster involves the use of antiviral medications, such as valaciclovir, acyclovir, and famciclovir 2, 3, 4, 5, 6.
- Valaciclovir has been shown to be at least as effective as acyclovir in controlling the symptoms of acute herpes zoster, and it alleviates zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 2.
- A study comparing valaciclovir and acyclovir found that valaciclovir accelerated the resolution of herpes zoster-associated pain and reduced the duration of postherpetic neuralgia 3.
- A meta-analysis of 14 randomized controlled trials found that 900-1000 mg valaciclovir with three times a day can improve the effective rate, shorten the blister stopping time, relieve the pain faster, and shorten the scabbing time without increasing the adverse reaction rate 4.
- Valaciclovir is also compared with famciclovir, and it is found that valaciclovir is more effective than acyclovir and equally effective as famciclovir at hastening the healing of zoster-associated pain and PHN 5.
- A systematic review and cost comparison found that oral famciclovir and valacyclovir are reasonable alternatives to oral acyclovir for treatment of active HZO in immunocompetent individuals, with simpler dosing schedules and a cost benefit that is consistent across Canada 6.
Treatment Options
- Valaciclovir: 1000 mg 3 times daily for 7 days 2, 3, 5, 6.
- Acyclovir: 800 mg 5 times daily for 7-10 days 2, 3, 4, 6.
- Famciclovir: 500 mg 3 times daily for 7 days 4, 5, 6.
Efficacy and Safety
- Valaciclovir is well tolerated, with nausea and headache being the most commonly reported adverse events 2.
- Acyclovir and famciclovir have similar efficacy and safety profiles to valaciclovir 3, 4, 5, 6.
- The adverse events profile of valaciclovir is similar to that seen with acyclovir or famciclovir 2.