How to Treat Shingles?

Things to note:

• Isolate from immunocompromised or pregnant non-immune individuals (who may develop severe chickenpox).
• Offer HIV test especially in patients < 50 years of age.

Medical Treatment:
Antiviral therapy, for:

• zoster in immunocompromised patients, provided that active lesions are still being formed, and
• in immunocompetent individuals provided they present within 72 hours of onset.

• Aciclovir, oral, 800 mg five times daily for 7 days (4 hourly missing the middle of the night dose).

For zoster with secondary dissemination or neurological involvement:

• Aciclovir, IV, 10 mg/kg administrerd over one hour 8 hourly for 7 days.
• The course can be completed with oral aciclovir 800 mg five times daily.

Eye involvement:
ADD

• Aciclovir opthalmic ointment 3%, applied into lower conjunctival sac, five times daily.

Secondary infection

• This is seldom present and is over-diagnosed.
• The vesicles in shingles often contain purulent material, and erythema is a cardinal feature of shingles.
• If there is suspected associated bacterial cellulitis:
• Flucloxacillin, oral, 500 mg 6 hourly for 5 days.

Pain

• Pain is often very severe and requires active control.
• Combination of different classes of analgesics is often necessary.
• Recommended therapy for acute phase of infection, e.g:
• Paracetamol, oral, 1 g 4-6 hourly when required to a maximum of 4 doses per 24 hours.

AND/OR
If pain is not adequately controlled:

• Tramadol, oral, 50 mg 6 hourly
• Although pain is rarely eliminated, treatment should reduce daily pain level, as well as the frequency, severity and duration of the pain flares.
• Neuropathic pain is best treated with amitriptyline. If this fails, consider the use of antiepileptics, e.g. carbamazepine or a weak opiate, e.g. tramadol. Concerns regarding addiction should not compromise adequate pain control with opioids.
• Utilise the least invasive route of medication administration, preferably oral.

Analgesics

• For chronic pain, analgesics must be administered regularly and not only when required (prn).
• Additional short-acting analgesia may be required 30 minutes prior to paininducing activity such as physiotherapy.
• Combinations of medications from different classes may have additive analgesic effects.

Non-opioid drugs:

• Paracetamol, oral, 1 g 6 hourly.

If no response, add non-steroidal anti-inflammatory drugs (NSAIDs).
NSAIDs, e.g:

• Ibuprofen, oral, 400-800 mg 8 hourly with meals.
• An additional night-time dose of a NSAID may be required.
• Can be used in combination with paracetamol or opioids.

Note:

• There are safety concerns with the long-term use of NSAIDs, including increased risk of CVS disease, renal impairment and GIT bleeding.
• If no response, add opioid drugs.
• Increase doses of opioids according to the individual need to overcome pain.
• Take into account the development of tolerance.
• In chronic pain, the correct dose is that which relieves the patients symptoms and, except for tramadol, may exceed the recommended dose used in other pain relief settings.
• Tramadol, oral, 50 mg, 6 hourly as a starting dose.
• May be increased to a maximum of 400 mg daily.

OR

• Morphine BP, short-acting solution, oral.
• Starting dose: 20 mg 4 hourly.
• Elderly, frail or patients less than 50 kg: 10 mg 4 hourly.
• Increase dose by 50 % every dosage interval if pain control is sub-optimal.
• Reduce the dosing interval if there is regular breakthrough pain.

OR

• Morphine, long-acting, oral, 30-60 mg 12 hourly.
• Titrate to desired effect.

• Manage nausea caused by opioids.

For constipation caused by opioids:

• Sennosides A and B, oral, 2 tablets at night.

For constipation in patients with potentially obstructive lesions:

• Lactulose, oral, 15 mL 12 hourly.

Adjuvant therapy
Adjuvant agents can enhance pain control by targeting specific pain mechanisms:

• Nerve injury pain,
• Burning paraesthesia,
• Neuropathic pain,
• Nerve root compreBetaion,
• HIV neuropathy,and
• Chemotherapeutic nerve injuries.

In addition to analgesia as above:

• Amitriptyline, oral, 10 mg at night.
• Titrate up to 75 mg at night.

AND/OR

• Carbamazepine, oral, 100 mg 12 hourly for 2 weeks.
• Then 200 mg 12 hourly.
• Titrate dose slowly up to 600 mg every 12 hours, depending on the response.

For nausea and vomiting:

• Metoclopramide, oral, 10-20 mg 8-12 hourly.

OR

• Metoclopramide, IV or IM, 10 mg 8 hourly.

For pruritus or nausea:

• Promethazine, oral/IV, 10 mg 6 hourly.

For anxiety:

• Diazepam, oral, 2-5 mg 12 hourly.

For colic:

• Hyoscine butylbromide, IV/oral, 10 mg 8 hourly.

Post-herpetic neuralgia:

• Initiate treatment with adjuvant therapy early.
• Amitriptyline, oral, 25 mg at night.
• Titrate as necessary to a maximum of 75 mg.

When to refer:

• To an ophthalmologist if there is ocular involvement with ophthalmic zoster (if the tip of the nose is involved then suspect ocular involvement)
• Positive Hutchinson sign, i.e. vesicle at the tip/side of the nose.
• Fluorescein staining of cornea (keratitis/ulceration).
• Decreased vision, i.e. a 2 line fall off in Snellen acuity in affected eye compared to healthy eye or afferent pupil defect.
• Red eye (uveitis or keratitis).
• Cranial nerve palsies.