How is herpes zoster ophthalmicus (HZO) in HIV infection treated?

Updated: Jul 21, 2021
  • Author: Luca Rosignoli, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Recommended treatment for herpes zoster ophthalmicus (HZO) in setting of systemic immunocompromise is intravenous acyclovir 10 mg/kg 3 times per day for 7 days, followed by oral acyclovir 800 mg to 1 g 3-5 times per day for an additional 7 days. This regimen is most effective when started within 72 hours of onset of the vesicular lesions.

Oral acyclovir has been demonstrated in a randomized clinical trial to reduce the shedding of the virus from the vesicles, decrease systemic spreading of the virus, and reduce the severity and duration of HZO complications (eg, dendritic keratitis, stromal keratitis, uveitis). However, oral acyclovir does not affect the incidence, severity, or duration of postherpetic neuralgia.

Famciclovir 500 mg 3 times per day for 7 days and valacyclovir 1000 mg 3 times per day for 7 days can be considered as alternative therapeutic options. However, use of valacyclovir has been associated with increased risk of thrombotic thrombocytopenic purpura and hemolytic-uremic syndrome in setting of concurrent HIV infection, If HZO is unresponsive to acyclovir, famciclovir, or valacyclovir, intravenous foscarnet should be considered. 

If intraocular inflammation is present, a topical cycloplegic agent (ie, scopolamine 0.25% tid) and a topical steroid (ie, prednisolone acetate 1% q1-2h) should be started.

Topical capsaicin, oral amitriptyline or gabapentin  may be useful in reducing the symptoms of postherpetic neuralgia.

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