When to Give Prednisone in Shingles
Prednisone should generally NOT be added to antiviral therapy for acute herpes zoster, as the modest benefit in acute pain reduction does not outweigh the significant risks of adverse effects, and it does not prevent postherpetic neuralgia. 1
Evidence Against Routine Corticosteroid Use
The highest quality evidence comes from a randomized controlled trial that directly addressed this question. When prednisolone (40 mg daily, tapered over 3 weeks) was added to acyclovir therapy, it provided only slight benefits during the acute phase—specifically faster rash healing on days 7 and 14, and marginally greater pain reduction during the first two weeks. However, there was no difference in the time to complete cessation of pain or in the frequency of postherpetic neuralgia at 6-month follow-up. 1 Importantly, patients receiving steroids reported more adverse events. 1
When Prednisone Might Be Considered (Rare Circumstances)
The American Academy of Dermatology suggests prednisone may be used as adjunctive therapy only in select cases of severe, widespread shingles flares, but this should be approached with extreme caution. 2
Specific criteria where consideration might occur:
- Severe, widespread disease in otherwise healthy, immunocompetent patients under age 50 2
- Only when combined with appropriate antiviral therapy (never as monotherapy) 1
- Only when started within 72 hours of rash onset alongside antivirals 1
Absolute Contraindications to Prednisone
Prednisone should be avoided in the following populations:
Immunocompromised Patients
- The CDC advises against prednisone in immunocompromised patients with shingles due to increased risk of disseminated infection 2
- This includes patients with HIV, cancer, organ transplant recipients, or those on chronic immunosuppressive medications 2, 3
- Immunocompromised patients may actually require temporary reduction or discontinuation of existing immunosuppressive medications during active herpes zoster 2, 3
High-Risk Populations
- Elderly patients (the population most susceptible to shingles) face significant risks from prednisone, including hypertension, myopathy, glaucoma, aseptic necrosis, cataracts, Cushing syndrome, weight gain, and osteopenia 2
- Patients with poorly controlled diabetes, history of steroid-induced psychosis, severe osteoporosis, or prior severe steroid toxicity 2
- Pregnant women 2
Active Complications
- Patients with ophthalmic involvement should never receive topical corticosteroids before establishing adequate antiviral therapy, as this can cause devastating progression of infection 3
- Disseminated herpes zoster (multi-dermatomal involvement, visceral involvement) 2, 3
The Correct Treatment Algorithm
Instead of adding prednisone, focus on:
Prompt antiviral therapy within 72 hours of rash onset with valacyclovir 1000 mg three times daily, famciclovir 500 mg three times daily, or acyclovir 800 mg five times daily for 7-10 days 2, 4
For immunocompromised patients or complicated disease, use intravenous acyclovir 10 mg/kg every 8 hours 2, 3
For acute pain management, use appropriate analgesics such as acetaminophen, NSAIDs, or opioids as needed 2, 5
For prevention of future episodes, administer the recombinant zoster vaccine (Shingrix) after recovery 2
Key Clinical Pitfall
The most common error is assuming that because prednisone reduces acute inflammation and pain in the first 1-2 weeks, it provides meaningful long-term benefit. The evidence clearly demonstrates that any short-term symptomatic improvement does not translate into reduced postherpetic neuralgia or improved long-term outcomes, while the adverse effects remain substantial. 1