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Comorbidities: A matter of concern in herpes zoster



Patients with certain underlying medical conditions are at risk of herpes zoster, and they include 12:




Physicians must be aware of other possible clinical manifestations of the disease and should not overlook herpes zoster. 3For instance, an atypical herpes zoster infection could be heralded by prodromic dental pain in elderly patients. 4


Challenges in diagnosis and management of herpes zoster in comorbid conditions




Take-home message
Odontogenic-like pain serves as a prodrome for reactivation of herpes zoster virus manifesting as trigeminal herpes zoster infection and near-synchronous with Ramsay Hunt syndrome.


Do you need to reassess the choice of antidiabetic medications in people with diabetes and herpes zoster?

The incidence of herpes zoster is much higher among people with diabetes. Certain medications such as dipeptidyl peptidase inhibitors (gliptins) are likely to increase the risk of herpes zoster. This increased risk is likely because of their immunomodulatory effects. 5

Herpes zoster management in diabetes
Management of herpes zoster in people with diabetes includes antiviral medications (acyclovir, famciclovir and valacyclovir), and adjuvant therapy with analgesics, neurotropic membrane stabilizers (pregabalin, gabapentin), and tricyclic antidepressants.
In addition to antiviral therapy, oral corticosteroids could provide modest benefits in terms of alleviating pain of herpes zoster and the reducing the incidence of postherpetic neuralgia.
6However, the use of corticosteroids has remained controversial and hence is not recommended in people with diabetes. 5


Patients with Inflammatory Bowel Disease: Overcoming practical dilemma of managing herpes zoster

Herpes zoster management algorithm in patients with IBD is provided in the image given below. 7




IBD Management in herpes zoster: Take-home messages

Management and prevention of herpes zoster in patients with immunocompromised inflammatory bowel disease (IBD) is a clinical quandary. 7

  • It is recommended to commence anti-varicella zoster therpay within 72 hours of onset of rash in all immunocompromised patients with IBD. 7
    • Oral valaciclovir
    • Oral famciclovir 
    • Intravenous acyclovir
  • The decision to withhold and restart immunosuppression in IBD patients with herpes zoster is customized, case-by-case. 7



  1. Kawai K, Yawn BP. Risk factors for herpes zoster: a systematic review and meta-analysis. Mayo Clin Proc. 2017;92(12):1806-1821.
  2. Côté-Daigneault J, Bessissow T, Nicolae MV. Herpes zoster incidence in inflammatory bowel disease patients: a population-based study. Inflamm Bowel Dis. 2019;25(5):914-918.
  3. Wollina U. Variations in herpes zoster manifestation. Indian J Med Res. 2017;145:294-298.
  4. Brooks JK, Rostami AM, McCorkle DC, et al. Trigeminal herpes zoster and Ramsay Hunt syndrome in an elderly adult: presentation with prodromal toothache. Gerodontology. 2018;35(3):276-278.
  5. Kalra S, Chawla A. Herpes zoster and diabetes. J Pak Med Assoc. 2016;66(8):1042-1043.
  6. Stankus JS, Dlugopolski  M, Packer D. Management of herpes zoster (shingles) and postherpetic neuralgia. Am Fam Physician. 2000;61(8):2437-2444.
  7. Côté-Daigneault J, Peerani F, MacMahon E, et al. Management and prevention of herpes zoster in the immunocompromised inflammatory bowel disease patient: a clinical quandary. Inflamm Bowel Dis. 2016;22:2538-2547.

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