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Medication recommendations in guidelines
Expert Consensus on the Management of Herpes Zoster-Related Pain (2021):
The goals of treatment are to relieve acute pain, promote healing of skin lesions, and prevent postherpetic neuralgia (PHN).
1. Antiviral drugs
1.1
It is recommended to apply the population first
- Patients over 50 years of age with any site occurring;
- Patients with shingles on the head and/or neck;
- Patients with herpes zoster at any site have the following symptoms: moderate to severe herpes zoster-related pain, hemorrhagic or necrotizing skin lesions, distribution involving more than one nerve segment, ectopic blisters, satellite lesions, or mucosal involvement;
- Immunocompromised;
- comorbid other skin-related conditions (e.g., atopic dermatitis);
- Patients on long-term glucocorticoids.
1.2
Indications for application
- Indications for antiviral use are unknown, but patients under 50 years of age with herpes zoster on the trunk or extremities should also be treated with antiviral therapy;
- It is recommended that all patients with herpes zoster without contraindications should receive a full course of antiviral therapy as soon as possible (within 48 to 72 hours).
1.3
Type of drug
- Nucleosides: acyclovir (click to jump to the rational use of drugs), valacyclovir, famciclovir;
- Nucleoside analogues: bromovudine;
- Non-nucleoside: sodium foscarnet.
1.4
Course of treatment
- It usually takes 7 days, and if new blisters still appear, it can be extended to 14 days after ruling out misdiagnosis or drug resistance.
2. Analgesic drugs
In the initial stage of the disease, the treatment of nociceptive pain is the mainstay, and then the treatment of neuropathic pain is gradually strengthened.
2.1
非甾体类抗炎药（NSAID）
- It is suitable for the control of nociceptive pain, and the analgesic effect on neuropathic pain is not obvious;
- In the early stage of the disease, if there are no relevant contraindications (peptic ulcer, abnormal liver and kidney function, etc.), it can be used as soon as possible, and the drug should be discontinued in time after the skin lesions have resolved.
2.2
Ion channel blockers
- Suitable for the control of neuropathic pain;
- calcium-channel blockers (gabapentin, pregabalin), which should be titrated gradually;
- Sodium channel blockers (lidocaine) can be administered intravenously, intrathecally, or transdermally, with transdermal patches being the most convenient and avoiding blisters, erosions, and hair.
2.3
Tricyclic antidepressants
- Suitable for the control of neuropathic pain;
- Including doxepin, amitriptyline, etc., combined with ion channel blockers can play a synergistic effect;
- It has analgesic effect, and it does not need to be used with anxiety and depression.
2.4
Serotonin (5-HT) and norepinephrine reuptake inhibitors
- Duloxetine and venlafaxine are representative drugs.
2.5
Opioids
- Early use, especially strong opioids, is not recommended;
- Moderate to severe pain that is not controlled by non-opioid analgesics may be considered as appropriate, with attention to addiction.
3. Glucocorticoids
- Whether it is currently used is controversial;
- In clinical practice, the use of herpes zoster in the acute phase can shorten the duration of pain in the acute phase and reduce the occurrence of PHN, which may be related to the anti-inflammatory effect.
4. Neurotrophic drugs
- It has a certain effect on relieving neuralgia, mainly drawing on the treatment of painful diabetic peripheral neuropathy;
- Vitamin B (such as vitamin B1, vitamin B12), vitamin C, gamma oryzanol, coenzyme A, etc.
5. Extended questions
● Acyclovir VS famciclovir, ganciclovir, who should choose for shingles treatment?
● For mild and moderate to severe "postherpetic neuralgia", which drugs should be used?
● For herpes zoster pain in special populations, the recommended treatment drugs are?......
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