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Oral Antivirals Revisited in the Treatment of Herpes Zoster

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Abstract

Oral antiviral agents currently represent the most important therapeutic keystone in the treatment of herpes zoster. Three oral antiviral agents are available for the treatment of herpes zoster: acyclovir, its derivative valacyclovir, and famciclovir. Meta-analysis of published data has shown that oral acyclovir significantly reduces various herpes zoster-related symptoms as well as the duration, intensity and prevalence of zoster-associated pain (ZAP). However, this drug does not influence postherpetic neuralgia. The newer agents famciclovir and valacyclovir exhibit a better oral bioavailability than acyclovir. These agents have demonstrated similar efficacy to acyclovir with ZAP and they require less frequent administration.

When initiated within 72 hours, oral antiviral therapy of herpes zoster is beneficial in selected, elderly immunocompetent patients, reducing the duration and intensity of ZAP and providing more rapid skin lesion healing. Oral antivirals are also of benefit in immunocompromised patients with uncomplicated herpes zoster. However, signs of cutaneous and visceral dissemination should be monitored; if signs occur, intravenous antiviral therapy is indicated.

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References

  1. Grose C. Varicella zoster virus infections: chickenpox, shingles, and varicella vaccine. In: Glaser R., Jones J.F., editors. Herpes virus infection. New York: Marcel Dekker Inc, 1994: 1117–85

    Google Scholar 

  2. Arvin A.M. Varicella zoster virus. In: Fields B.N., Knipe D.M., Howley P.M., et al., editors. Fields virology. 3rd ed. Philadelphia (PA): Lippincott-Publishers, 1996: 2547–85

    Google Scholar 

  3. Sanders H.W.A. Herpes zoster in de huisartspraktijk [doctoral thesis]. Nijmegen: University of Nijmegen, 1968

    Google Scholar 

  4. Dworkin R.H., Perkins F.M., Nagasako E.M. Prospects for the prevention of postherpetic neuralgia in herpes zoster patients. Clin J Pain 2000; 16 (2 Suppl.): S90–100

    Article  PubMed  CAS  Google Scholar 

  5. Levin M.J. Vaccination against zoster. Pain Res Clin Manag 2001; 11: 131–42

    Google Scholar 

  6. Petursson G., Helgason S., Gudmundsson S., et al. Herpes zoster in children and adolescents. Pediatr Infect Dis J 1998; 17: 905–8

    Article  PubMed  CAS  Google Scholar 

  7. Latif R., Shope T.C. Herpes zoster in normal and immunocompromised children. Am J Dis Child 1983; 137: 801–2

    PubMed  CAS  Google Scholar 

  8. Terada K., Kawano S., Yoshihiro K., et al. Characteristics of herpes zoster in otherwise normal children. Pediatr Infect Dis J 1993; 12: 960–1

    Article  PubMed  CAS  Google Scholar 

  9. Kakourou T., Theodoridou M., Mostrou G., et al. Herpes zoster in children. J Am Acad Dermatol 1998; 39: 207–10

    Article  PubMed  CAS  Google Scholar 

  10. Harding S.P., Porter S.M. Oral aciclovir in herpes zoster ophthalmicus. Curr Eye Res 1991; 10: 177–82

    Article  PubMed  Google Scholar 

  11. Cobo M.L., Foulks G.N., Liesegang T.J., et al. Oral aciclovir in the therapy of acute herpes zoster ophthalmicus. Ophthalmology 1985; 92: 1574–83

    PubMed  CAS  Google Scholar 

  12. Cobo M. Reduction of the ocular complications of herpes zoster ophthalmicus by oral acyclovir. Am J Med 1988; 85 Suppl. 2a: 90–3

    PubMed  CAS  Google Scholar 

  13. Borruat F.X., Buechi E.R., Piquet B., et al. Prevention des complications oculaires de l’herpes zoster ophthalmique par un traitement adequat d’acyclovir. Klin Monatsbl Augenheilkd 1991; 198: 358–60

    Article  PubMed  CAS  Google Scholar 

  14. Herbort C.P., Buechi E.R., Piquet B., et al. High-dose oral acyclovir in acute herpes zoster ophthalmicus: the end of the corticosteroid era. Curr Eye Res 1991; 10: 171–5

    Article  PubMed  Google Scholar 

  15. Colin J., Prisant O., Cochener B., et al. Comparison of the efficacy and safety of valaciclovir and acyclovir for the treatment of herpes zoster ophthalmicus. Ophthalmology 2000; 107: 1507–11

    Article  PubMed  CAS  Google Scholar 

  16. Balfour Jr H.H. Varicella-zoster virus infections in the immunocompromised host: natural history and treatment. Scand J Infect Dis 1991; 23 Suppl. 80: 69–74

    Google Scholar 

  17. Balfour H.H. Varicella zoster infections in immunocompromised hosts. Am J Med 1988; 85 Suppl. 2A: 68–73

    PubMed  Google Scholar 

  18. Mandal B.K. Herpes zoster and the immunocompromised. J Infect 1987; 14: 15–9

    Article  Google Scholar 

  19. Nikkels A.F., Delvenne P., Sadzot-Delvaux C., et al. Distribution of varicella zoster virus and herpes simplex virus in disseminated fatal infections. J Clin Pathol 1996; 49: 243–8

    Article  PubMed  CAS  Google Scholar 

  20. Han C.S., Miller W., Haake R., et al. Varicella zoster infection after bone marrow transplantation: incidence, risk factors and complications. Bone Marrow Transplant 1994; 13: 277–83

    PubMed  CAS  Google Scholar 

  21. Nikkels A.F., Snoeck R., Rentier B., et al. Chronic verrucous varicella zoster virus skin lesions: clinical, histological, molecular and therapeutic aspects. Clin Exp Dermatol 1999; 24: 346–53

    Article  PubMed  CAS  Google Scholar 

  22. Nikkels A.F., Piérard G.E. Recognition and treatment of shingles. Drugs 1994; 48: 528–48

    Article  PubMed  CAS  Google Scholar 

  23. O’Brien J.J., Campoli-Richards D.M. Acyclovir: an updated review of its antiviral activity, pharmacokinetic properties and therapeutic efficacy. Drugs 1989; 37: 233–309

    Article  PubMed  Google Scholar 

  24. Wagstaff A.J., Faulds D., Goa K.J. Aciclovir: a reappraisal of its antiviral activity, pharmacokinetic properties and therapeutic efficacy. Drugs 1994; 47: 153–205

    Article  PubMed  CAS  Google Scholar 

  25. Perry C.M., Faulds D. Valaciclovir: a review of its antiviral activity, pharmacokinetic properties and therapeutic efficacy in herpes virus infections. Drugs 1996; 52: 754–72

    Article  PubMed  CAS  Google Scholar 

  26. Ormrod D., Goa K. Valaciclovir: a review of its use in the management of herpes zoster. Drugs 2000; 59: 1317–40

    Article  PubMed  CAS  Google Scholar 

  27. Piérard G.E., Nikkels A.F. Le médicament du mois: le valaciclovir (Zelitrex). Rev Med Liege 1997; 52: 553–5

    PubMed  Google Scholar 

  28. Nikkels A.F., Piérard G.E. Comment je traite: le zona. Rev Med Liege 1999; 54: 71–5

    PubMed  CAS  Google Scholar 

  29. Nikkels A.F., Piérard G.E. Current therapies for shingles. Exp Opin Invest Drugs 1996; 5: 185–96

    Article  CAS  Google Scholar 

  30. Perry C.M., Wagstaff A.J. Famciclovir: a review of its pharmacological properties and therapeutic efficacy in herpes virus infections. Drugs 1995; 50: 396–415

    Article  PubMed  CAS  Google Scholar 

  31. Dworkin R.H., Carrington D., Cunningham A., et al. Assessment of pain in herpes zoster: lessons learned from antiviral trials. Antiviral Res 1997; 33: 73–85

    Article  PubMed  CAS  Google Scholar 

  32. Anonymous. A blue print for studies in herpes zoster. Expert Opin Herpes 1994; 7: 1–3

    Google Scholar 

  33. Wood M.J., Balfour H., Beutner K., et al. How should zoster trials be conducted? J Antimicrob Chemother 1995; 36: 1089–101

    Article  PubMed  CAS  Google Scholar 

  34. Tyring S., Barbarash R.A., Nahlik J.E., et al. Collaborative famciclovir herpes zoster study group: famciclovir for the treatment of acute herpes zoster: effects on acute disease and postherpetic neuralgia. Ann Intern Med 1995; 123: 89–96

    PubMed  CAS  Google Scholar 

  35. Kalman C.M., Laksin O.L. Herpes zoster and zosteriform herpes simplex virus infections in immunocompetent patients. Am J Med 1986; 81: 775–8

    Article  PubMed  CAS  Google Scholar 

  36. Bowsher D. The lifetime occurrence of herpes zoster and prevalence of postherpetic neuralgia: a retrospective study in an elderly population. Eur J Pain 1999; 3: 335–42

    Article  PubMed  Google Scholar 

  37. Burgoon C.F., Burgoon J.S., Baldridge G.D. The natural history of herpes zoster. JAMA 1957; 164: 265–9

    Article  Google Scholar 

  38. Söltz-Szöts J. Kritische Bemerkungen sur Klinik und Therapie des Herpes Zoster. Zentralbl Haut u Geschlechtskrankheiten 1965; 38: 123–7

    Google Scholar 

  39. Helgason S., Petursson G., Gudmundsson S., et al. Prevalence of postherpetic neuralgia after a first episode of herpes zoster: prospective study with a long term follow up. BMJ 2000; 321: 794–6

    Article  PubMed  CAS  Google Scholar 

  40. Helgason S., Sigurdsson J.A., Gudmundsson S. The clinical course of herpes zoster: a prospective study in primary care. Eur J Gen Pract 1996; 2: 12–6

    Article  Google Scholar 

  41. De Moragas J.M., Kierland R.R. The outcome of patients with herpes zoster. Arch Dermatol 1957; 75: 193–6

    Article  Google Scholar 

  42. Wood M.J., Ogan P.H., McKendrick M.W., et al. Efficacy of oral acyclovir treatment of acute herpes zoster. Am J Med 1988; 85: 79–83

    PubMed  CAS  Google Scholar 

  43. Morton P., Thomson A.N. Oral acyclovir in the treatment of herpes zoster in general practice. N Z Med J 1989; 102: 93–5

    PubMed  CAS  Google Scholar 

  44. Beutner K.R., Friedman D.J., Forszpaniak C., et al. Valaciclovir compared with aciclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother 1995; 39: 1546–53

    Article  PubMed  CAS  Google Scholar 

  45. Wood M.J., Johnson R.W., McKendrick M.W., et al. A randomized trial of aciclovir for 7 days or 21 days with and without prednisolone for the treatment of acute herpes zoster. N Engl J Med 1994; 330: 896–900

    Article  PubMed  CAS  Google Scholar 

  46. Huff J.C., Bean B., Balfour H.H., et al. Therapy of herpes zoster with oral aciclovir. Am J Med 1988; 85: 84–9

    Article  PubMed  CAS  Google Scholar 

  47. Wassilew S.W., Reimlinger S., Nasemann T., et al. Oral acyclovir for herpes zoster: a double-blind controlled trial in normal subjects. Br J Dermatol 1987; 117: 495–501

    Article  PubMed  CAS  Google Scholar 

  48. Hoang-Xuan T., Buchi E.B., Herbort C.P., et al. Oral aciclovir for herpes zoster ophthalmicus. Ophthalmology 1992; 99: 1062–71

    PubMed  CAS  Google Scholar 

  49. Whithley R.J., Weiss H., Gnann J.W., et al. Acyclovir with and without prednisone for the treatment of herpes zoster: a randomized, placebo-controlled trial. Ann Intern Med 1996; 125: 376–83

    Google Scholar 

  50. Vander Straten M., Carrasco D., Lee P., et al. Reduction of postherpetic neuralgia in herpes zoster. J Cutan Med Surg 2001; 5: 409–16

    Article  Google Scholar 

  51. Crooks R.J., Jones D.A., Fiddian A.P. Zoster-associated chronic pain: an overview of clinical trials with aciclovir. Scand J Infect Dis 1991; 23 Suppl. 78: 62–8

    Google Scholar 

  52. Wood M.J., Kay R., Dworkin R.H., et al. Oral acyclovir therapy accelerates pain resolution in patients with herpes zoster: a meta-analysis of placebo-controlled trials. Clin Infect Dis 1996; 22: 341–7

    Article  PubMed  CAS  Google Scholar 

  53. McKendrick M.W., Care C., Borke C., et al. Oral aciclovir in herpes zoster. J Antimicrob Chemother 1984; 14: 661–5

    Article  PubMed  CAS  Google Scholar 

  54. McKendrick M.W., McGill J.I., Wood M.J. Lack of effect of acyclovir on postherpetic neuralgia. BMJ 1989; 298: 431

    Article  PubMed  CAS  Google Scholar 

  55. Degreef H., and the Famciclovir Herpes Zoster Clinical Study Group. Famciclovir, a new oral antiherpes drug: results of the first controlled clinical study demonstrating its efficacy and safety in immunocompetent patients. Int J Antimicrob Agents 1994; 4: 241–6

    Article  PubMed  CAS  Google Scholar 

  56. Anonymous. Famciclovir safe and effective for management of shingles. AIDS Patient Care STDS 1997; 11: 198

    Google Scholar 

  57. Tyring S., Belanger R., Bezwoda W., et al. A randomized, double-blind trial of famciclovir versus acyclovir for the treatment of localized dermatomal herpes zoster in immunocompromised patients. Cancer Invest 2001; 19: 13–22

    Article  PubMed  CAS  Google Scholar 

  58. Tyring S., Engst R., Corriveau C., et al. Famciclovir for ophthalmic zoster: a randomised aciclovir controlled study. Br J Ophthalmol 2001; 85: 576–81

    Article  PubMed  CAS  Google Scholar 

  59. Eaglestein W.H., Katz R., Brown J.A. The effects of early corticosteroid therapy on the skin eruption and pain of herpes zoster. JAMA 1970; 211: 1681–3

    Article  Google Scholar 

  60. Esmann V., Geil J.P., Kroon S., et al. Prednisolone does not prevent postherpetic neuralgia. Lancet 1987; II: 126–9

    Article  Google Scholar 

  61. Dworkin R.H., Boon R.J., Griffin D.R.G., et al. Postherpetic neuralgia: impact of famciclovir, age, rash severity, and acute pain in herpes zoster patients. J Infect Dis 1998; 178 Suppl. 1: 71–5

    Article  Google Scholar 

  62. Whitley R.J., Gnann J.W. Herpes zoster: focus on treatment in older adults. Antiviral Res 1999; 44: 145–54

    Article  PubMed  CAS  Google Scholar 

  63. Whitley R.J., Gnann Jr J.W., Weiss H.L., et al. Unique clinical trial design: combination acyclovir plus prednisone therapy of localized zoster in the normal host. Antiviral Res 1996; 29: 67–8

    Article  PubMed  CAS  Google Scholar 

  64. Tyring S.K., Beutner K.R., Tucker B.A., et al. Antiviral therapy for herpes zoster: randomized, controlled clinical trial of valaciclovir and famciclovir therapy in immunocompetent patients 50 years and older. Arch Fam Med 2000; 9: 863–9

    Article  PubMed  CAS  Google Scholar 

  65. Choo P.W., Galil K., Donahue J.G., et al. Risk factors for postherpetic neuralgia. Arch Intern Med 1997; 157: 1217–24

    Article  PubMed  CAS  Google Scholar 

  66. Alper B.S., Lewis P.R. Does treatment of acute herpes zoster prevent or shorten postherpetic neuralgia? J Fam Pract 2000; 49: 255–64

    PubMed  CAS  Google Scholar 

  67. Johnson R. Herpes zoster-predicting and minimizing the impact of post-herpetic neuralgia. J Antimicrob Chemother 2001; 47 Suppl. 1: 1–8

    Article  PubMed  CAS  Google Scholar 

  68. Wacker P., Hartmann O., Benhamou E., et al. Varicella zoster virus infections after autologous bone marrow transplantation in children. Bone Marrow Transplant 1989; 4: 191–4

    PubMed  CAS  Google Scholar 

  69. Perren R.J., Powles R.L., Easton D., et al. Prevention of herpes zoster in patients by long term oral acyclovir after allogenic bone marrow transplantation. Am J Med 1988; 85 Suppl. 2A: 99–101

    PubMed  CAS  Google Scholar 

  70. Van Den Broek P.J., Van Der Meer J.W., Mulder J.D., et al. Limited value of acyclovir in the treatment of uncomplicated herpes zoster: a placebo controlled study. Infection 1984; 12: 338–41

    Article  PubMed  Google Scholar 

  71. Marshall T. Postherpetic neuralgia: treatment with amitriptyline is cheaper than with aciclovir. BMJ 2001; 322: 860–1

    PubMed  CAS  Google Scholar 

  72. Whitley R.J., Gnann Jr J.W., Hinthorn D., et al. Disseminated herpes zoster in the immunocompromised host: a comparative trial of acyclovir and vidarabine. J Infect Dis 1992; 165: 450–5

    Article  PubMed  CAS  Google Scholar 

  73. Meyers J.D. Treatment of the varicella zoster infections in immunocompromised patients. Res Clin Forums 1986; 9: 65–74

    Google Scholar 

  74. Peterslund N.A. The treatment of herpes zoster infections. Scand J Infect Dis 1985; 17 Suppl. 47: 80–4

    Google Scholar 

  75. Petterson E., Hovi T., Ahonen J., et al. Prophylactic oral aciclovir after renal transplantation. Transplantation 1985; 39: 279–81

    Article  Google Scholar 

  76. Masaoka T., Hiraoka A., Teshima H., et al. Varicella zoster infection in immunocompromised patients. J Med Virol 1993; Suppl. 1: 82–4

    Article  PubMed  Google Scholar 

  77. Levin M.J., Zaia J.A., Hershey B.J., et al. Topical acyclovir treatment of herpes zoster in immunocompromised patients. J Am Acad Dermatol 1985; 13: 590–6

    Article  PubMed  CAS  Google Scholar 

  78. Rothe M.J., Feder Jr H.M., Grant-Kels J.M. Oral acyclovir therapy for varicella and zoster infections in pediatric and pregnant patients: a brief review. Pediatr Dermatol 1991; 8: 236–7

    Article  PubMed  CAS  Google Scholar 

  79. Sempere A., Sanz G.F., Senent L., et al. Long-term acyclovir prophylaxis for prevention of varicella zoster virus infection after autologous blood stem cell transplantation in patients with acute leukemia. Bone Marrow Transplant 1992; 10: 495–8

    PubMed  CAS  Google Scholar 

  80. Ljungman P., Lonnquist B., Ringden O., et al. A randomized trial of oral versus intravenous acyclovir for treatment of herpes zoster in bone marrow transplant recipients. Bone Marrow Transplant 1989; 4: 613–5

    PubMed  CAS  Google Scholar 

  81. Ladriere M., Bibes B., Rabaud C., et al. Varicella zoster virus infection after bone marrow transplant: unusual presentation and importance of prevention. Presse Med 2001; 30: 1151–4

    PubMed  CAS  Google Scholar 

  82. Yagi T., Karasuno T., Hasegawa T., et al. Acute abdomen without cutaneous signs of varicella zoster virus infection as a late complication of allogeneic bone marrow transplantation: importance of empiric therapy with acyclovir. Bone Marrow Transplant 2000; 25: 1003–5

    Article  PubMed  CAS  Google Scholar 

  83. Stemmer S.M., Kinsman K., Tellschow S., et al. Fatal noncutaneous visceral infection with varicella-zoster virus in a patient with autologous bone marrow tranplantation. Clin Inf Dis 1993; 16: 497–9

    Article  CAS  Google Scholar 

  84. Novelli V.M., Marshall W.C., Yeo J., et al. Acyclovir administered perorally in immunocompromised children with varicella zoster infections. J Infect Dis 1984; 149: 478

    Article  PubMed  CAS  Google Scholar 

  85. Höglund M., Ljungman P., Weller S. Comparable aciclovir exposures produced by oral aciclovir in immunocompromised cancer patients. J Antimicrob Chemother 2001; 47: 855–61

    Article  PubMed  Google Scholar 

  86. Bomgaars L., Duran C., Khan S., et al. The pharmacokinetics of valaciclovir in immunocompromised children [abstract]. Clin Pharmcol Ther 2000; 69: PI58

    Google Scholar 

  87. Levin M.J. Use of varicella vaccines to prevent herpes zoster in older individuals. Arch Virol 2001; 146 Suppl. 17: 151–60

    Google Scholar 

  88. Straus S.E. Varicella-zoster virus immunity and prevention: a conference perspective. Arch Virol 2001; 146 Suppl. 17: 173–8

    Google Scholar 

  89. Takahashi M., Kamiya H., Asano Y., et al. Immunization of the elderly to boost immunity against varicella-zoster virus (VZV) as assessed by VZV skin test reaction. Arch Virol 2001; 146 Suppl. 17: 161–72

    Google Scholar 

  90. Gershon A.A. The current status of live attenuated varicella vaccine. Arch Virol 2001; 146 Suppl. 17: 1–6

    Google Scholar 

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  1. University Medical Center, University of Liège, Sart Tilman, B-4000, Liège, Belgium

    Arjen F. Nikkels & Gérald E. Piérard

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Nikkels, A.F., Piérard, G.E. Oral Antivirals Revisited in the Treatment of Herpes Zoster. Am J Clin Dermatol 3, 591–598 (2002). https://doi.org/10.2165/00128071-200203090-00001

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