Should You Continue Hydroxychloroquine During Acute Shingles Treatment?
Continue hydroxychloroquine during acute herpes zoster (shingles) infection while treating the viral infection appropriately with antivirals. The benefits of maintaining disease control in your autoimmune condition outweigh the theoretical concerns about immunosuppression during active shingles.
Rationale for Continuing Hydroxychloroquine
Evidence from Autoimmune Disease Guidelines
- Multiple high-quality guidelines strongly recommend against discontinuing hydroxychloroquine in patients with systemic lupus erythematosus (SLE) and other autoimmune diseases 1.
- Discontinuation of hydroxychloroquine is associated with a 2.5-fold increased risk of disease flares (HR 2.50,95% CI: 1.08-5.58), including severe flares of lupus nephritis 1.
- The KDIGO 2024 guidelines emphasize that hydroxychloroquine has protective effects against infection and should be maintained to prevent organ damage and vascular complications 1.
Guidance During Active Infections
- The American College of Rheumatology COVID-19 guidance explicitly states that hydroxychloroquine may be continued during symptomatic viral infections 1.
- This recommendation reflects the understanding that hydroxychloroquine has immunomodulatory rather than profoundly immunosuppressive effects 1.
- The drug's mechanism involves pH-dependent inhibition of viral replication and modulation of inflammatory cytokines, which may actually provide some benefit during viral infections 1.
Treatment Approach for Shingles While on Hydroxychloroquine
Antiviral Therapy is Essential
- High-dose intravenous acyclovir remains the treatment of choice for VZV infections in immunocompromised hosts 1.
- For mild cases with transient immunosuppression, oral acyclovir, famciclovir, or valacyclovir can be used 1.
- Treatment should be initiated promptly to prevent dissemination and complications like postherpetic neuralgia 1.
Monitoring Considerations
- Watch for signs of disseminated VZV infection, which can occur in 10-20% of immunosuppressed patients without prompt antiviral therapy 1.
- Monitor for complications including postherpetic neuralgia, which affects approximately 58% of patients in autoimmune disease populations 2.
Understanding the Risk Context
Hydroxychloroquine and Herpes Zoster Risk
- Research shows that hydroxychloroquine use is associated with increased herpes zoster risk (adjusted OR 1.43-1.95) 3, 4, 5.
- However, this increased risk is dose-dependent and significantly lower than risks associated with high-dose corticosteroids (≥10 mg/day prednisone: OR 2.30) or biologics (OR 2.53) 3, 4.
- The risk is particularly elevated when hydroxychloroquine is combined with other immunosuppressants 5.
Important Caveat
- Once shingles has already developed, the primary concern shifts from prevention to treatment and preventing autoimmune disease flares 1.
- The risk of a severe lupus or rheumatoid arthritis flare from stopping hydroxychloroquine during acute illness substantially outweighs theoretical concerns about ongoing modest immunosuppression 1.
Considerations for Other Immunosuppressants
If you are taking additional immunosuppressive medications beyond hydroxychloroquine:
- Conventional DMARDs (methotrexate, azathioprine) and biologics should generally be temporarily withheld during symptomatic viral infections 1.
- Glucocorticoids should be continued at the lowest effective dose to prevent adrenal insufficiency and control underlying disease 1.
- Cyclophosphamide carries the highest risk for severe herpes zoster (OR 2.69) and requires careful consideration 3.
Prevention for the Future
Vaccination Recommendations
- The recombinant zoster vaccine (Shingrix) is safe and effective in patients with autoimmune diseases, including those on hydroxychloroquine 1.
- Flare rates following vaccination are low (5.5% overall, with only 0-2% moderate-to-severe flares) 1.
- Vaccination should be strongly considered after recovery from acute shingles to prevent recurrence 6, 7.
Post-Exposure Prophylaxis
- Patients on immunosuppressive therapy who are non-immune to VZV should be informed about post-exposure prophylaxis options following contact with chickenpox or shingles 1.