What are the IASP recommendations for the treatment of herpes zoster (shingles)?

Updated: Jan 25, 2019
  • Author: Camila K Janniger, MD; Chief Editor: Dirk M Elston, MD  more...
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Answer

The 2007 International Association for the Study of Pain (IASP) recommendations for the management of herpes zoster offer the most comprehensive guidance covering treatment of both immunocompromised and immunocompetent patients.

IASP recommendations for immunocompetent patients are as follows [1] :

  • Topical antiviral therapy is not recommended.

  • Oral antiviral therapy is recommended for first-line treatment for patients 50 years or older, moderate or severe pain, moderate or severe rash, or those who have non truncal involvement.

  • Oral antiviral therapy should be considered for patients younger than 50 years with mild pain and rash and truncal involvement because of the risk of developing postherpetic neuralgia (PHN).

  • Brivudin, famciclovir, and valacyclovir show greater efficacy than acyclovir.

  • Antiviral therapy should be initiated within 72 hours of the onset of the rash, but it may be considered for patients presenting more than 72 hours after the onset of the rash when there are cutaneous, motor, neurologic, or ocular complications or in patients of advanced age or in severe pain.

  • Pain management approaches should be individualized based on pain severity, underlying conditions, and prior response to specific medications.

  • For mild to moderate pain, acetaminophen or NSAIDs may be used alone or in combination with weak opioids such as codeine or tramadol.

  • For moderate to severe pain, strong opioids such as oxycodone or morphine may be used.

  • If moderate to severe pain has not responded rapidly to treatment with an opioid analgesic, the addition of gabapentin or pregabalin, tricyclic antidepressants (TCAs) (especially nortriptyline), or corticosteroids (eg, prednisone) may be considered.

  • For those patients with moderate or severe pain who are unable to tolerate an opioid analgesic, treatment with gabapentin or pregabalin, TCAs (especially nortriptyline), or corticosteroids (eg, prednisone), alone and in combination, can be considered.

  • For patients with pain that is inadequately controlled by antiviral agents in combination with oral analgesic medications and/or corticosteroids, referral to a pain specialist to evaluate eligibility for neural blockade.


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