Treatment of herpes zoster ophthalmicus

For assessment of herpes zoster ophthalmicus, see Assessment of infectious keratitis.

Note: Consult an ophthalmologist in all cases of herpes zoster ophthalmicus.

Consult an ophthalmologist in all cases of herpes zoster ophthalmicus. Keratitis is one of the most common ocular manifestations of herpes zoster ophthalmicusLewis, 2020. Corneal ulcers in herpes zoster ophthalmicus have prolonged healing times, and may be complicated by corneal perforation.

Systemic antiviral therapy for herpes zoster ophthalmicus reduces acute pain, duration of rash, viral shedding and ocular complicationsMeyer, 2022Werner, 2017. Start treatment as soon as the diagnosis is suspected, ideally within 72 hours of the onset of rash; however, to reduce the risk of ocular complications, treatment can be started at any time if active vesicles are present, or in patients with immune compromise or of advanced ageMeyer, 2022Werner, 2017. Topical aciclovir has no role in the initial treatment of herpes zoster ophthalmicus.

Note: Do not use topical aciclovir for initial treatment of herpes zoster ophthalmicus.

Oral antiviral therapy is appropriate for patients with herpes zoster ophthalmicus who are immunocompetent and do not have fulminant infection. Use:

1valaciclovir 1 g (child 2 years or older: 20 mg/kg up to 1 g) orally, 8-hourly for 7 days12. For dosage adjustment in adults with kidney impairment, see valaciclovir dosage adjustment valaciclovir valaciclovir valaciclovir

OR

2famciclovir 500 mg orally, 8-hourly for 7 days34. For dosage adjustment in adults with kidney impairment, see famciclovir dosage adjustment famciclovir famciclovir famciclovir

OR

2aciclovir 800 mg (child: 20 mg/kg up to 800 mg) orally, 5 times daily for 7 days7. For dosage adjustment in adults with kidney impairment, see aciclovir oral dosage adjustment. aciclovir aciclovir aciclovir

Limited data suggest that valaciclovir (a prodrug of aciclovir) is safe in pregnancy, and some prescribers prefer it because it has a more convenient (8-hourly) dosing regimen. There are insufficient data to support use of famciclovir in pregnancy.

Intravenous aciclovir is required for patients with herpes zoster ophthalmicus who have immune compromise, or nonresponding or fulminant infection. Use:

aciclovir intravenously, 8-hourly aciclovir aciclovir aciclovir

adult and child older than 12 years: 10 mg/kg5. For dosage adjustment in adults with kidney impairment, see aciclovir intravenous dosage adjustment

child younger than 5 years: 20 mg/kg or 500 mg/m267

child 5 years to 12 years: 15 mg/kg or 500 mg/m267.

Patients with undiagnosed HIV infection may present initially with herpes zoster infection, including shingles. Shingles is an indicator condition for HIV testing8. If shingles is identified, offer HIV testing, regardless of whether the patient has behavioural or epidemiological risk factors for HIV infection9.

1 An oral liquid formulation of valaciclovir is not commercially available; for formulation options for children or people with swallowing difficulties, see Don’t Rush to Crush, which is available for purchase from the Advanced Pharmacy Australia website or through a subscription to eMIMSplus.Return
2 Valaciclovir is not licensed in Australia for use in children younger than 12 years; however, it is licensed internationally for use in children older than 2 years.Return
3 At the time of writing, the quantity of famciclovir required for a course of treatment for patients who do not have immune compromise is not available on the Pharmaceutical Benefits Scheme (PBS). See the PBS website for current information. Return
4 Famciclovir is not used in children.Return
5 Aciclovir dosing in obesity is poorly defined; however, limited data support dosing based on adjusted body weight in adults and ideal body weight in children. For simplicity, some centres recommend a maximum dosing weight of 100 kg (eg 1 g for 10 mg/kg doses, 1.5 g for 15 mg/kg doses).Return
6 Use the online calculator to determine body surface area.Return
7 Aciclovir dosing in obesity is poorly defined; however, limited data support dosing based on ideal body weight in children.Return
8 Indicator conditions for HIV testing are conditions that are seen in people with HIV infection (including undiagnosed infection), conditions that share a transmission route with HIV (eg sexually transmissible infections), or conditions for which management is altered in people with HIV infection (eg tuberculosis).Return
9 In patients who need to be started on therapy for HIV, see Shingles in adults with HIV infection for advice on starting antiretroviral therapy.Return