Management should be directed toward shortening the course of the disease, preventing postherpetic neuralgia in patients over 50 years of age, and preventing dissemination in immunocompromised patients. Acyclovir or the newer antiherpes drugs valacyclovir or famciclovir accelerate healing and reduce acute pain, but they do not reduce the incidence of postherpetic neuralgia.
The newer drugs have greater bioavailability and are more effective in the treatment of HZ.
The use of systemic corticosteroids to prevent postherpetic neuralgia in patients over 50 years of age is controversial; a recent review of the data indicated a reduction of pain and disability during the first 2 weeks but no effect on the incidence or severity of post-herpetic neuralgia.
33,34
Some clinicians advocate the use of a combination of intralesional steroids and local anesthetics to decrease healing time and prevent postherpetic neuralgia, but a controlled study of this therapy has not been performed.
Effective therapy for postherpetic neuralgia includes application of capsaicin, a substance extracted from hot chili peppers.
40
Topical capsaicin is safe but must be used for a prolonged period to be effective and may cause a burning sensation of the skin. When topical capsaicin therapy is ineffective, use of a tricyclic antidepressant or gabapentin is indicated.
41
Chemical or surgical neurolysis may be necessary in refractory cases (see Chapter 11, Orofacial Pain).