The goal of herpes zoster (HZ) treatment is to relieve pain in the acute phase, to limit the spread and duration of skin lesions, and to prevent or alleviate postherpetic neuralgia (PHN) and other acute and chronic complications. Antiviral therapy and HZ pain-relief measures are strategies to reach the goal.

According to national and international recommendations or guidelines for the management of HZ systemic antiviral therapy is strongly recommended for immunosuppressed patients, patients beyond the age of 50 years and patients at any age with HZ in the head and neck area, especially in patients with zoster ophthalmicus and zoster oticus. Further indications are severe HZ on the trunk and extremities, and in patients with severe atopic dermatitis and severe ekzema.

Multiple randomized clinical trials have shown that aciclovir, brivudin, famciclovir and valaciclovir significantly shorten the healing process of acute HZ, prevent or alleviate pain and other acute and chronic complications, particularly when given within 48 h to 72 h after onset of the rash. In immunocompromized patients and patients with persisting zoster ophthalmicus and zoster oticus antiviral therapy should be initiated even when presenting >72 h after rash onset. Concerning PHN brivudin, famciclovir and valaciclovir proved to be significantly more effective than oral aciclovir. The therapy of choice for HZ in severely immunocompromised patients remains intravenous aciclovir.

Brivudin has a markedly higher in-vitro activity against VZV than aciclovir, valaciclovir and famciclovir and, thus offers a once-a day dosing regimen. This may improve compliance, especially amongst the elderly, who often require extensive co-medication. All four agents are well tolerated by the patients and do not differ with regard to safety. However, brivudin must not be used together with 5-fluorouracil or its derivatives. Clinical data from „off-label“ use of brivudin in the therapy of HZ in immunosuppressed patients demonstrated efficacy and tolerability of the drug when used in an out-patient manner.

Early initiation of antiviral therapy and patient compliance are preconditions for the efficacy of treatment in terms of stopping viral replication, reducing neural damage and preventing PHN. To reach an effective relief of acute pain analgesic therapy should be initiated promptly.

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