Should we prophylactically apply topical mupirocin to a herpes zoster rash in a patient receiving tofacitinib?

Topical Mupirocin for Herpes Zoster Rash in Tofacitinib-Treated Patients

Topical mupirocin should not be routinely applied to herpes zoster lesions as prophylaxis against bacterial superinfection, as there is no evidence supporting this practice and it may interfere with lesion assessment and healing. 1, 2

Primary Management Focus

The priority in managing herpes zoster during tofacitinib therapy is immediate antiviral treatment and drug interruption, not bacterial prophylaxis:

• Discontinue tofacitinib immediately upon diagnosis and do not restart until all cutaneous lesions have fully resolved (typically 15–22 days after onset). 1
• Initiate oral valacyclovir 1 g three times daily for 7 days within 48–72 hours of rash onset for maximal antiviral efficacy. 1, 2
• The increased herpes zoster risk with JAK inhibition stems from blockade of interferon-mediated antiviral pathways, making rapid drug interruption and antiviral therapy essential. 1

Why Topical Antibiotics Are Not Indicated

• Topical therapies (including topical antivirals) are substantially less effective than systemic therapy for herpes zoster and are not recommended. 2
• Bacterial superinfection of herpes zoster lesions is uncommon in immunocompetent hosts and does not warrant prophylactic antibiotic use. 2
• The primary complications of herpes zoster in tofacitinib-treated patients are viral dissemination, post-herpetic neuralgia, and CNS involvement—not bacterial superinfection. 1, 3, 4

Appropriate Skin Care During Active Infection

• Keep lesions clean and dry; avoid applying any products to active vesicular lesions. 2
• Cover lesions with clothing or dressings to minimize transmission risk to susceptible individuals until all lesions have crusted. 2
• Emollients may be used to prevent excessive dryness only after lesions have crusted, not during the active vesicular phase. 2

When to Consider Escalation (Not Topical Antibiotics)

• Switch to intravenous acyclovir 10 mg/kg every 8 hours if disseminated disease, CNS involvement, or severe immunocompromise is present. 2, 3
• For patients experiencing a second herpes zoster episode while on tofacitinib, initiate long-term antiviral prophylaxis with valacyclovir when the drug is restarted. 1
• Administer the two-dose recombinant zoster vaccine (Shingrix) after complete resolution of the acute episode, waiting at least 2 months before vaccination. 1, 2

Critical Pitfalls to Avoid

• Never apply topical antibiotics prophylactically to herpes zoster lesions, as this practice lacks evidence and may obscure clinical assessment of lesion progression. 2
• Never continue tofacitinib during active herpes zoster infection, as ongoing JAK inhibition impairs interferon-mediated viral clearance and heightens the risk of severe or disseminated disease. 1, 4
• Do not delay systemic antiviral therapy beyond 72 hours of rash onset, as efficacy in reducing acute pain and preventing post-herpetic neuralgia diminishes significantly after this window. 1, 2