How is herpes zoster ophthalmicus (HZO) in HIV infection treated?

Updated: Jun 12, 2019
  • Author: Robert A Copeland, Jr, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Recommended treatment for herpes zoster ophthalmicus (HZO) is intravenous acyclovir 10 mg/kg 3 times per day for 7 days, followed by oral acyclovir 800 mg to 1 g 3-5 times per day for an additional 7 days. This regimen is most effective when started within 72 hours of onset of the vesicular lesions. This treatment reduces the frequency of recurrences.

Oral acyclovir has been demonstrated in a randomized clinical trial to reduce the shedding of the virus from the vesicles, decrease systemic spreading of the virus, and reduce the severity and duration of HZO complications (eg, dendritic keratitis, stromal keratitis, uveitis). However, oral acyclovir does not affect the incidence, severity, or duration of postherpetic neuralgia.

Famciclovir 500 mg 3 times per day for 7 days and valacyclovir 1000 mg 3 times per day for 7 days has an advantage of causing fewer adverse effects. If HZO is unresponsive to acyclovir, famciclovir, or valacyclovir, intravenous foscarnet should be tried. 

Topical antiviral agents have not been shown to be effective for the management of HZO.

If intraocular inflammation is present, a topical cycloplegic agent (ie, scopolamine 0.25% tid) and a topical steroid (ie, prednisolone acetate 1% q1-2h) should be started.

Generally, it is recommended that oral steroids be avoided because of the risk of further immunosuppression of the patient and exacerbation of the infection. However, oral steroids have been used by dermatologists for the treatment of HZO to reduce the incidence of postherpetic neuralgia in patients older than 60 years.

Alternatively, topical capsaicin 0.25% ointment applied to the involved skin twice daily, or amitriptyline 25 mg by mouth 3 times daily may be useful in reducing the symptoms of postherpetic neuralgia.

In case of persistent punctate keratopathy, treatment with copious, nonpreserved ocular lubricant ointments, bandage contact lenses, or tarsorrhaphy may be needed.

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