Does herpes zoster ophthalmicus require steroid treatment?

Herpes Zoster Ophthalmicus: Steroid Treatment Recommendations

Primary Treatment Recommendation

Systemic antiviral therapy is the essential first-line treatment for herpes zoster ophthalmicus, while topical corticosteroids may be added for specific ocular inflammatory complications (stromal keratitis, uveitis) but only in conjunction with antiviral coverage—never as monotherapy. 1, 2

Antiviral Therapy (Mandatory Foundation)

All patients with herpes zoster ophthalmicus require systemic antiviral therapy initiated within 72 hours of rash onset:

• Acyclovir 800 mg five times daily for 7 days 1
• Valacyclovir 1000 mg every 8 hours for 7 days 1
• Famciclovir 500 mg three times daily for 7 days 1

The evidence strongly supports that 7 days of treatment is sufficient—extending to 14 days provides no additional benefit 3. Early antiviral treatment reduces late ocular inflammatory complications from 50-71% in untreated patients to approximately 29% 3, 4.

When Corticosteroids Are Indicated

Topical corticosteroids should only be used for specific inflammatory complications that develop during or after the acute phase:

Stromal Keratitis

• Add topical corticosteroids at minimum effective dose when stromal inflammation develops 2
• Must maintain concurrent oral antiviral therapy 2
• Use low-penetration agents (fluorometholone, loteprednol, or rimexolone) to minimize IOP elevation and cataract risk 2

Uveitis

• Coordinate treatment with ophthalmologist before initiating steroids 2
• Combine topical/periocular corticosteroids with systemic antivirals 2
• Consider systemic corticosteroids for severe cases under specialist guidance 2

Critical Contraindications and Pitfalls

Never use corticosteroids in the following scenarios:

• Active epithelial keratitis or dendritic ulcers - corticosteroids potentiate viral replication and worsen infection 2, 5
• Before confirming the diagnosis - starting steroids prior to ophthalmologic examination may mask accurate diagnosis or worsen herpetic disease 2
• As monotherapy without antiviral coverage - this is absolutely contraindicated 2, 1

The distinction between HSV and VZV epithelial disease versus stromal/uveal inflammation is critical: epithelial disease requires antivirals alone, while stromal/uveal disease may benefit from steroids but only with antiviral coverage 2.

Monitoring Requirements for Steroid Use

When topical corticosteroids are prescribed, mandatory follow-up includes:

• Regular IOP measurements to detect steroid-induced glaucoma 2
• Periodic pupillary dilation to evaluate for cataract formation 2
• Slit-lamp biomicroscopy at each visit 2
• Slow taper to minimum effective dose once inflammation is controlled 2

Clinical Outcomes Without Steroids

Systemic antivirals alone significantly reduce complications: only 13% of treated patients experience post-herpetic neuralgia (none requiring analgesics), compared to higher rates historically 3. The reduction in stromal keratitis and uveitis incidence with antivirals alone demonstrates that steroids are adjunctive, not primary therapy 4.

Special Populations

Immunocompromised patients require more aggressive antiviral therapy with higher doses and potentially longer duration, but the same principles apply regarding selective steroid use only for inflammatory complications 1.