When pain is severe, opioids are indicated. Initially, begin with an agent such as tramadol (a synthetic opioid analgesic) or codeine. If severe pain continues, consider a stronger opioid, such as hydrocodone, oxycodone, or morphine. Pain medication is best given on a schedule rather than “as needed” and should be used for a short term. According to Schmader,13 a commonly used approach is to start with a short-acting medication at an oxycodone equi-analgesic dose of 5 mg, given 4 times daily. The dose is then titrated until pain is reduced. If the prolonged use of opioids is necessary, referral to a pain specialist is recommended.8,18
Some clinicians add corticosteroids to the treatment regimen, starting with 60 mg of oral prednisone daily and tapering the dose over 10 to 14 days. Some studies show that this regimen decreases pain and hastens healing. However, corticosteroids should be avoided in patients with hypertension, diabetes, gastritis, or osteoporosis.13,16
Herpes zoster ophthalmicus
Herpes zoster ophthalmicus (HZO) can occur when VZV is reactivated in the trigeminal ganglion within the ophthalmic division of the trigeminal nerve. This occurs in 10% to 20% of patients with herpes zoster.19 When the frontal branch of the ophthalmic nerve is affected, ocular involvement can develop.
A vesicular rash extending along the side of the nose within the distribution of the nasociliary nerve, called Hutchinson’s sign, portends ocular pathology. The eyelid, conjunctiva, and sclera become erythematous and swollen. The cornea becomes involved in 65% of cases of HZO. Acute retinal necrosis can also occur. Patients have decreased vision, photophobia, loss of corneal sensitivity, and intense pain. The complications of HZO can last for days to months.19 Stroke, a life-threatening complication of HZO, is secondary to vasculopathy of a cerebral artery.20
The patient requires a prompt and comprehensive ophthalmologic examination. According to Vrcek et al,20 systemic antiviral treatment is necessary in HZO. According to Cohen,21 early treatment with 500 mg of oral famciclovir 3 times daily or with 1 g of oral valacyclovir 3 times daily for 7 days reduces ocular complications. For keratitis, effective treatment consists of topical ganciclovir applied 5 times a day until healing occurs, then twice a day for 2 to 4 weeks even if oral antiviral agents are ineffective. Oral opiate and nonsteroidal anti-inflammatory medications are frequently indicated for pain. Topical corticosteroids should be used judiciously, and intraocular pressure must be monitored by an ophthalmologist. If the pressure rises significantly above normal values, treatment is required.
According to Roat,22 topical corticosteroid treatment consists of 1% prednisolone acetate instilled every hour for uveitis or 4 times daily for keratitis initially, with the interval lengthened as symptoms lessen. The pupil should be dilated with 1 drop of 1% atropine or 1 drop of 0.25% scopolamine 3 times daily.
According to Catron and Hern,23 in high-risk cases, admission for the intravenous administration of acyclovir is indicated. Admission is recommended for persons with known immunodeficiency, on immunosuppressive medications, or with involvement of multiple dermatomes, retinal involvement, corneal ulceration, or serious bacterial superinfection.
Complications of herpes zoster
Postherpetic neuralgia (PHN) is the most common complication of herpes zoster (Table 3). It occurs in approximately 18% of patients aged older than 50 years and 33% of patients aged older than 80 years.24,25