重點(我自己整理的)
1. 50歲以上, 發生併發症的機率上升, 考慮給予抗病毒藥物
2. 出現水泡的 72小時內治療效果最好
3. 若出現水泡超過 72 小時, 但仍有新的病灶產生, 還是建議考慮給予抗病毒藥物治療
4. 水泡若已經結痂, 抗病毒藥物沒有明顯療效.
2. 出現水泡的 72小時內治療效果最好
3. 若出現水泡超過 72 小時, 但仍有新的病灶產生, 還是建議考慮給予抗病毒藥物治療
4. 水泡若已經結痂, 抗病毒藥物沒有明顯療效.
5. 帶狀泡疹後的神經痛. 另外寫一篇筆記(Postherpetic Neuralgia帶狀泡疹神經痛)
(美國神經病學學會(AAN)、神經性疼痛特別興趣小組(NeuPSIG) 和歐洲神經學會聯合會(EFNS) 均推薦口服三環類抗抑鬱藥(TCA)、普瑞巴林和5% 利多卡因貼劑作為一線藥物療法。)
下面是用google翻譯 uptodate 內容.
最前面有一段google 沒自動翻譯到. google翻譯的程式邏輯還是有缺陷.
The management of herpes zoster includes:
●Antiviral therapy to hasten healing of cutaneous lesions and to decrease the duration and severity of acute neuritis. Whether antiviral therapy decreases the risk of post-herpetic neuralgia (PHN) is less clear. (See 'Antiviral therapy' below.)
●中、重度急性神經炎患者的鎮痛。(參見下文‘急性神經炎的鎮痛’)
已確診的 PHN 的治療將在別處討論。
抗病毒治療 — 抗病毒治療的目標是：
●減輕急性神經炎相關疼痛的嚴重程度和持續時間
●促進皮膚病變更快癒合
●防止新病灶形成
●減少病毒脫落，降低傳播風險
●預防 PHN
多項證據表明，抗病毒治療可加速帶狀皰疹皮膚病變和急性神經炎的消退[5-7]。然而，尚不清楚抗病毒治療是否可以預防 PHN，因為研究結果相互矛盾，部分原因是疼痛評估方法、PHN 定義和隨訪時間長度不同 [5-8]。
發病後 ≤ 72 小時 — 我們建議對出現臨床症狀 72 小時內出現的無併發症帶狀皰疹患者進行抗病毒治療。應在此時間範圍內開始抗病毒治療，以最大限度地發揮治療的潛在益處。
對於 50 歲以上的患者，抗病毒治療的益處似乎最大，因為帶狀皰疹疼痛通常持續時間較長 [5,9]。儘管抗病毒治療對 50 歲以下患者的療效尚未得到充分研究，但抗病毒治療繼發不良事件的風險非常低。
(50歲以下病患, 因為身體狀況比較好. 所以不管有沒有接受治療, 大多數會順利痊癒. 因此無法顯示出抗病毒藥物的明顯好處. 吃不吃抗病毒藥物都預後良好).
發病後 >72 小時 — 如果在發病時出現新病灶，我們會在 72 小時後進行抗病毒治療，因為這表明病毒正在復制 [10]。然而，對於免疫功能正常的人，在病變出現超過 72 小時後開始抗病毒治療的臨床效用尚不清楚。對於病變已結痂的患者，抗病毒治療的益處可能很小。
藥物的選擇 — 核苷類似物阿昔洛韋、伐昔洛韋和泛昔洛韋是治療急性帶狀皰疹感染的首選抗病毒藥物。口服抗病毒治療通常足以用於無並發症帶狀皰疹的初始治療，除非患者有復雜疾病的證據（例如急性視網膜壞死、腦炎）。(參見下文‘複雜性帶狀皰疹’)
與阿昔洛韋相比，我們更喜歡伐昔洛韋或泛昔洛韋，因為需要較低的給藥頻率。小型比較試驗並不支持其中一種優於另一種的功效[11-13]。
治療帶狀皰疹的劑量如下：
●伐昔洛韋：1000mg，每日3次，連續7天
|●泛昔洛韋：500 mg，每日 3 次，持續 7 天
●阿昔洛韋：800 mg，每日 5 次，持續 7 天
阿昔洛韋及其類似物的清除取決於腎功能，中度至重度腎功能不全者需要調整劑量。劑量信息可以在 UpToDate 內的 Lexicomp 藥物信息主題中找到。
儘管用於治療帶狀皰疹感染的劑量高於單純皰疹病毒通常所需的劑量，但這些核苷類似物在目前推薦的劑量下具有完善的安全記錄。不良事件並不常見，但可能包括噁心、腹瀉或頭痛。有關各個代理的更多詳細信息可在其他地方找到。(參見“阿昔洛韋：概述”和“伐昔洛韋：概述”和“泛昔洛韋：
支持這些藥物治療帶狀皰疹療效的數據包括：
●口服阿昔洛韋 — 口服阿昔洛韋一直是帶狀皰疹治療的主要支柱。然而，其生物利用度差以及需要頻繁每日給藥（800 mg，每日五次），促使開發了新一代抗病毒藥物（伐昔洛韋和泛昔洛韋），其藥代動力學得到改善，給藥頻率更低[5,6,14-16]。
在一項涉及 691 名患者（平均年齡 62 歲）的四項安慰劑對照試驗的薈萃分析中，那些在皮疹發作後 48 至 72 小時內接受阿昔洛韋（800 毫克，每日 5 次）治療的患者更有可能得到緩解中度/重度急性神經炎（風險比 [HR] 1.46；95% CI 1.1-1.93）和 PHN，定義為皮疹消退後三個月和六個月時出現疼痛（HR 1.8；95% CI 1.35-2.43） [5]。在隨後的一項薈萃分析中，其中包括一項額外的安慰劑對照試驗，抗病毒治療可將 PHN（定義為六個月內的任何疼痛）風險降低 46% [6]。
●泛昔洛韋 — 泛昔洛韋是噴昔洛韋的前藥，在胃腸道吸收良好。然後它在腸壁和肝臟中迅速轉化為活性化合物噴昔洛韋，它對水痘帶狀皰疹病毒具有廣泛的活性[9,16]。
在 419 名患有無並發症帶狀皰疹的免疫功能正常成人（平均年齡 50 歲）中進行了一項安慰劑對照臨床試驗，以評估標準劑量和高劑量泛昔洛韋（500 或 750 mg，每日 3 次）與安慰劑的療效 [9]。所有患者在出疹後 72 小時內開始治療，並治療 7 天。經過五個月的隨訪後，與安慰劑相比，泛昔洛韋可適度改善病變癒合率（中位時間為 5 至 6 天，而中位時間為 7 天）。雖然三個治療組之間 PHN 的發生率沒有差異，但與安慰劑相比，使用泛昔洛韋治療，無論劑量如何，都可以選擇性縮短 PHN 的中位持續時間（低和高劑量分別為 62 天和 55 天）。劑量泛昔洛韋，分別與 119 天）。
●伐昔洛韋 — 伐昔洛韋也能很好地從胃腸道吸收。它在體內迅速轉化為阿昔洛韋，從而使阿昔洛韋的生物利用度增加三到五倍[16,17]。
在一項對 1141 名免疫功能正常的帶狀皰疹成人（平均年齡 68 歲）進行的隨機、雙盲研究中，比較了伐昔洛韋（1000 mg，口服，每日 3 次，持續 7 或 14 天）與阿昔洛韋（800 mg，口服 5 次）的療效和安全性。每天一次，持續 7 天）超過六個月的隨訪[17]。所有治療組的皮膚病變消退率相似。然而，與阿昔洛韋相比，伐昔洛韋 7 或 14 天加速了急性神經炎的緩解（伐昔洛韋的中位疼痛持續時間分別為 38 和 44 天，而阿昔洛韋為 51 天）。此外，與阿昔洛韋組相比，聯合伐昔洛韋組中疼痛持續六個月的患者比例略低（19% vs 26%）。較長療程的伐昔洛韋沒有觀察到額外的益處。
阿昔洛韋 - 用於治療帶狀皰疹：
成人和 12 歲及以上兒童 - 800 毫克，每天 5 次，持續 7 至 10 天。
12 歲以下兒童——用途和劑量必須由醫生決定。
下面是 uptodate 原文
The management of herpes zoster includes:
●Antiviral therapy to hasten healing of cutaneous lesions and to decrease the duration and severity of acute neuritis. Whether antiviral therapy decreases the risk of post-herpetic neuralgia (PHN) is less clear. (See 'Antiviral therapy' below.)
●Analgesia for patients with moderate to severe acute neuritis. (See 'Analgesia for acute neuritis' below.)
The treatment of established PHN is discussed elsewhere. (See "Postherpetic neuralgia", section on 'Treatment'.)
Antiviral therapy — The goals of antiviral therapy are to [3,4]:
●Lessen the severity and duration of pain associated with acute neuritis
●Promote more rapid healing of skin lesions
●Prevent new lesion formation
●Decrease viral shedding to reduce the risk of transmission
●Prevent PHN
Several lines of evidence suggest that antiviral therapy hastens resolution of cutaneous lesions and the acute neuritis of herpes zoster [5-7]. However, it is unclear if antiviral therapy prevents PHN because of conflicting study results, which are due in part to different methodologies of pain assessment, definitions of PHN, and length of follow-up [5-8].
≤72 hours after onset — We recommend antiviral therapy for patients with uncomplicated herpes zoster who present within 72 hours of clinical symptoms. Antiviral therapy should be initiated within this time frame to maximize the potential benefits of treatment. (See 'Choice of agent' below.)
The benefit of antiviral therapy appears to be greatest in patients older than 50 years of age, in whom the pain of zoster generally persists longer [5,9]. Although the efficacy of antiviral therapy in patients less than 50 years of age has not been as well studied, the risk of adverse events secondary to antiviral therapy is very low.
>72 hours after onset — We administer antiviral therapy after 72 hours if new lesions are appearing at the time of presentation, as this indicates ongoing viral replication [10]. However, the clinical utility of initiating antiviral therapy more than 72 hours after the onset of lesions in immunocompetent persons is unknown. There is likely minimal benefit of antiviral therapy in the patient who has lesions that have encrusted.
Choice of agent — The nucleoside analogues acyclovir, valacyclovir, and famciclovir are the preferred antivirals for treatment of acute herpes zoster infection. Oral antiviral therapy is usually sufficient for the initial treatment of uncomplicated herpes zoster, unless the patient has evidence of complicated disease (eg, acute retinal necrosis, encephalitis). (See 'Complicated zoster' below.)
We prefer valacyclovir or famciclovir compared with acyclovir given the need for less frequent dosing. Small comparative trials do not support the efficacy of one over the other [11-13].
The doses used to treat herpes zoster are as follows:
●Valacyclovir: 1000 mg three times daily for seven days
|●Famciclovir: 500 mg three times daily for seven days
●Acyclovir: 800 mg five times daily for seven days
Acyclovir and its analogues are dependent upon renal function for clearance and dose adjustment is needed in moderate to severe renal insufficiency. Dosing information can be found in the Lexicomp drug information topics within UpToDate.
Although the doses used to treat herpes zoster infection are higher than those typically required for herpes simplex virus, these nucleoside analogs have well-established safety records at the currently recommended doses. Adverse events are uncommon, but can include nausea, diarrhea, or headache. More detailed information about the individual agents is found elsewhere. (See "Acyclovir: An overview" and "Valacyclovir: An overview" and "Famciclovir: An overview".)
Data supporting the efficacy of these agents for the treatment of herpes zoster include:
●Oral acyclovir — Oral acyclovir has been the mainstay of herpes zoster treatment. However, its poor bioavailability and need for frequent daily dosing (800 mg five times daily) prompted the development of later generation antiviral agents (valacyclovir and famciclovir) with improved pharmacokinetics and lower dosing frequency [5,6,14-16].
In a meta-analysis of four placebo-controlled trials involving 691 patients (mean age 62 years), those who received acyclovir (800 mg five times daily) administered within 48 to 72 hours of the onset of rash were more likely to have resolution of moderate/severe acute neuritis (hazard ratio [HR] 1.46; 95% CI 1.1-1.93) and PHN, defined as the presence of pain at three and six months after resolution of the rash (HR 1.8; 95% CI 1.35-2.43) [5]. In a subsequent meta-analysis, which included one additional placebo-controlled trial, antiviral therapy decreased the risk of PHN (as defined by any pain at six months) by 46 percent [6].
●Famciclovir — Famciclovir, the prodrug of penciclovir, is well absorbed from the gastrointestinal tract. It is then rapidly converted in the intestinal wall and liver to the active compound penciclovir, which has broad activity against varicella-zoster virus [9,16].
A placebo-controlled clinical trial was conducted in 419 immunocompetent adults (mean age 50 years) with uncomplicated zoster to evaluate the efficacy of standard-dose and high-dose famciclovir (500 or 750 mg three times daily) with placebo [9]. All patients initiated therapy within 72 hours of the rash and were treated for seven days. After five months of follow-up, famciclovir was associated with a modest improvement in lesion healing rates compared with placebo (median five to six versus seven days). While there was no difference in the incidence of PHN among the three treatment arms, the use of famciclovir therapy, regardless of dose, conferred a selective reduction in the median duration of PHN compared with placebo (62 and 55 days with low- and high-dose famciclovir, respectively versus 119 days).
●Valacyclovir — Valacyclovir is also well absorbed from the gastrointestinal tract. It is rapidly converted to acyclovir in vivo, thereby providing a three- to fivefold increase in acyclovir bioavailability [16,17].
In a randomized, double-blind study of 1141 immunocompetent adults with herpes zoster (mean age 68 years), the efficacy and safety of valacyclovir (1000 mg orally three times daily for 7 or 14 days) was compared with acyclovir (800 mg orally five times daily for seven days) over six months of follow-up [17]. Cutaneous lesions resolved at similar rates in all treatment groups. However, valacyclovir for 7 or 14 days accelerated the resolution of acute neuritis compared with acyclovir (median duration of pain 38 and 44 days, respectively, for valacyclovir compared with 51 days for acyclovir). In addition, the proportion of patients with pain persisting for six months was modestly lower in the combined valacyclovir arms compared with the acyclovir arm (19 versus 26 percent). No additional benefit was observed with a longer duration of valacyclovir.
Acyclovir- For treatment of shingles:
Adults and children 12 years of age and older—800 mg five times a day for seven to ten days.
Children up to 12 years of age—Use and dose must be determined by the doctor.
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