What is the appropriate workup and treatment for herpes zoster (shingles)?

From the Guidelines

Workup and Treatment of Herpes Zoster (Shingles)

The most effective approach for managing shingles involves initiating antiviral medication as soon as possible, ideally within 72 hours of rash onset, with options including acyclovir, valacyclovir, or famciclovir 1.

Antiviral Medications

• Acyclovir: 800mg orally 5 times a day for 7-10 days
• Valacyclovir: 1g orally 3 times a day for 7-10 days
• Famciclovir: 500mg orally 3 times a day for 7-10 days

Pain Management

Pain management is crucial and can be achieved with:

• Acetaminophen: 650-1000mg orally every 4-6 hours as needed
• Ibuprofen: 400-600mg orally every 4-6 hours as needed
• For severe pain, consider gabapentin 300-600mg orally 3 times a day or pregabalin 75-150mg orally 2 times a day 1.

Additional Considerations

• Topical capsaicin cream or lidocaine patches may be used for localized pain relief.
• Corticosteroids, such as prednisone 40-60mg orally daily for 7-10 days, can be considered to reduce inflammation and pain, especially in patients with severe symptoms or at high risk for complications 1.
• Assess the patient for any complications, such as ocular involvement, and refer them to a specialist if necessary.

From the FDA Drug Label

Herpes Zoster Infections : Acyclovir tablets is indicated for the acute treatment of herpes zoster (shingles). The appropriate treatment for herpes zoster (shingles) is Acyclovir tablets for acute treatment, as indicated in the drug label 2.

• The label does not provide information on the workup for herpes zoster.
• The label only mentions the treatment of herpes zoster with Acyclovir. No conclusion can be drawn regarding the workup for herpes zoster.

From the Research

Diagnosis and Presentation

• Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus, which is the same virus that causes chickenpox 3, 4, 5.
• The disease typically presents with a maculopapular rash, usually unilateral and confined to a single dermatome, accompanied by burning pain, which can precede the rash by several days and persist for several months after the rash resolves 3, 5.
• Patients may also experience malaise, headache, and low-grade fever before the rash appears 5.

Treatment

• Antiviral medications such as acyclovir, valacyclovir, and famciclovir are effective in treating herpes zoster, and are most effective when started within 72 hours after the onset of the rash 3, 4, 6, 5.
• Valacyclovir has been shown to be at least as effective as acyclovir in controlling the symptoms of acute herpes zoster, and may alleviate zoster-associated pain and postherpetic neuralgia faster than acyclovir 6.
• The addition of an orally administered corticosteroid can provide modest benefits in reducing the pain of herpes zoster and the incidence of postherpetic neuralgia 3.
• Treatment for postherpetic neuralgia, a common complication of herpes zoster, includes topical lidocaine or capsaicin, and oral gabapentin, pregabalin, or tricyclic antidepressants 5.

Prevention

• The varicella zoster virus vaccine has been shown to decrease the incidence of herpes zoster, and is approved for adults 50 years and older 5.
• The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends this vaccine for adults 60 years and older, except for certain immunosuppressed patients 5.

Special Considerations

• Ocular involvement in herpes zoster can lead to rare but serious complications, and generally merits referral to an ophthalmologist 3.
• Patients with postherpetic neuralgia may require narcotics for adequate pain control, and may also benefit from the use of tricyclic antidepressants or anticonvulsants, often given in low dosages 3.
• Capsaicin, lidocaine patches, and nerve blocks can also be used in selected patients to manage pain associated with herpes zoster and postherpetic neuralgia 3.