Can steroids be prescribed for an adult with a recent herpes zoster outbreak?

Corticosteroids for Shingles: Not Recommended as Standard Therapy

Corticosteroids should not be routinely prescribed for adults with herpes zoster (shingles), as the evidence shows they do not prevent postherpetic neuralgia and carry significant risks that outweigh any modest short-term pain benefit. 1, 2

Why Corticosteroids Are Not Recommended

Lack of Efficacy for Key Outcomes

• Corticosteroids do not reduce the incidence of postherpetic neuralgia, which is the most important complication to prevent in shingles patients 3
• While smaller trials suggested benefit, larger, better-designed controlled trials have consistently failed to demonstrate that oral corticosteroids prevent postherpetic neuralgia more effectively than placebo 3
• Corticosteroids may provide statistically significant but clinically questionable improvement in acute pain only, without affecting the long-term outcome that matters most 3

Significant Safety Concerns

• The use of oral corticosteroids carries serious risks including increased susceptibility to infections, hypertension, myopathy, glaucoma, aseptic necrosis, cataracts, Cushing syndrome, weight gain, and osteopenia 1
• These risks are particularly elevated in elderly patients, who are the population most commonly affected by shingles 2
• The Mayo Clinic specifically warns that prednisone use carries significant risks in elderly patients who are most susceptible to shingles 1

Contraindications in High-Risk Populations

• Corticosteroids should generally be avoided in immunocompromised patients with shingles due to increased risk of disseminated infection 1
• Patients with compromised immune systems should not use corticosteroids during active shingles, as it can increase the risk of severe disease and dissemination 1
• Immunocompromised patients include those with HIV, cancer, or on chronic systemic immunosuppression 1

The Evidence-Based Treatment Algorithm

First-Line Therapy: Antivirals Only

Initiate oral antiviral therapy within 72 hours of rash onset 1, 4:

• Valacyclovir 1000 mg three times daily for 7-10 days (preferred due to superior bioavailability and less frequent dosing) 1
• Famciclovir 500 mg three times daily for 7-10 days (equally effective alternative) 1
• Acyclovir 800 mg five times daily for 7-10 days (requires more frequent dosing but remains effective) 1, 4

Continue treatment until all lesions have completely scabbed, not just for an arbitrary 7-day period 1

When to Escalate to Intravenous Therapy

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

• Disseminated disease (≥3 dermatomes, visceral involvement, or hemorrhagic lesions)
• Facial or ophthalmic involvement with risk of cranial nerve complications
• Central nervous system complications (encephalitis, meningitis, Guillain-Barré syndrome)
• Severe immunosuppression
• Lack of clinical improvement after 7-10 days of oral therapy

Adjunctive Therapy for Pain Management

For acute neuropathic pain during active shingles 1:

• Gabapentin titrated up to 2400 mg per day in divided doses (first-line for neuropathic pain) 1
• Over-the-counter analgesics (acetaminophen, ibuprofen) for mild pain 1
• Topical ice or cold packs to reduce pain and swelling 1

Avoid topical antivirals entirely, as they are substantially less effective than systemic therapy 1

Special Circumstances Where Corticosteroids Might Be Considered

The American Academy of Dermatology suggests that prednisone may be used as adjunctive therapy to antivirals only in select cases of severe, widespread shingles flares 1, but this should be:

• Reserved for exceptional cases only
• Always combined with appropriate antiviral therapy
• Avoided in patients with poorly controlled diabetes, history of steroid-induced psychosis, severe osteoporosis, or prior severe steroid toxicity 1
• Never used as monotherapy

Critical Pitfalls to Avoid

1. Do not prescribe corticosteroids with the expectation of preventing postherpetic neuralgia—the evidence clearly shows they do not accomplish this goal 3

2. Do not use corticosteroids in immunocompromised patients, as this can worsen viral replication and increase dissemination risk 1

3. Do not delay or substitute corticosteroids for antiviral therapy—antivirals are the only evidence-based treatment that reduces complications 1, 4

4. Do not apply topical corticosteroid cream to active shingles lesions, as this can increase the risk of severe disease and dissemination 1

5. Do not initiate immunomodulatory therapy (including corticosteroids) during active chickenpox or herpes zoster infection—this is contraindicated 1

The Bottom Line

Focus on prompt antiviral therapy within 72 hours of rash onset, which is proven to accelerate healing, reduce acute pain, and prevent complications. 1, 4 Corticosteroids add minimal benefit for acute pain while introducing substantial risks, particularly in the elderly population most affected by shingles. The modest short-term pain reduction does not justify the serious adverse effects and lack of impact on the most important outcome: preventing postherpetic neuralgia. 2, 3