What is the treatment for Herpes Zoster (Shingles)?

From the Guidelines

Treatment of herpes zoster should involve oral antiviral therapy with valacyclovir (1000 mg three times daily for 7 days), famciclovir (500 mg three times daily for 7 days), or acyclovir (800 mg five times daily for 7-10 days) started within 72 hours of rash onset to reduce pain, accelerate healing, and potentially decrease the risk of postherpetic neuralgia. For most patients, this approach is sufficient, but for immunocompromised patients or those with ophthalmic involvement, hospitalization and intravenous acyclovir (10 mg/kg every 8 hours) may be necessary 1. Pain management is crucial and may include acetaminophen, NSAIDs, or in more severe cases, short-term opioids. For neuropathic pain, gabapentin (starting at 300 mg daily and titrating up) or pregabalin may be beneficial. Topical treatments like lidocaine patches (5%) can provide localized relief. Keeping the rash clean and dry helps prevent secondary bacterial infections. Patients should avoid contact with pregnant women who have never had chickenpox, immunocompromised individuals, and newborns until lesions crust over.

Some key considerations in the treatment of herpes zoster include:

• The importance of early initiation of antiviral therapy, ideally within 72 hours of rash onset, to maximize benefits 1
• The preference for valacyclovir and famciclovir due to their better bioavailability and simpler dosing schedules compared to acyclovir
• The need for hospitalization and intravenous acyclovir in immunocompromised patients or those with severe complications like ophthalmic involvement 1
• The role of pain management and supportive care in improving patient outcomes and quality of life

In terms of specific treatment guidelines, the Infectious Diseases Society of America recommends high-dose IV acyclovir for compromised hosts, while oral acyclovir, famciclovir, and valacyclovir are beneficial for otherwise healthy hosts 1. The KDIGO clinical practice guideline for the care of kidney transplant recipients also recommends treatment with oral acyclovir or valacyclovir for uncomplicated herpes zoster, and intravenous acyclovir for disseminated or invasive disease 1. Overall, the goal of treatment is to reduce morbidity, mortality, and improve quality of life by effectively managing the symptoms and complications of herpes zoster.

From the FDA Drug Label

Herpes Zoster VALTREX is indicated for the treatment of herpes zoster (shingles) in immunocompetent adults. In the active-controlled trial, 545 patients were treated with 1 of 3 doses of famciclovir three times daily or with acyclovir 800 mg five times daily. Herpes Zoster Infections : Acyclovir tablets is indicated for the acute treatment of herpes zoster (shingles). The treatment of Herpes Zoster includes:

• Valacyclovir (PO): indicated for the treatment of herpes zoster (shingles) in immunocompetent adults 2
• Famciclovir (PO): patients should be advised to initiate treatment as soon as possible after a diagnosis of herpes zoster 3
• Acyclovir (PO): indicated for the acute treatment of herpes zoster (shingles) 4

From the Research

Treatment Options for Herpes Zoster

• Antiviral medications such as valaciclovir, famciclovir, and aciclovir are commonly used to treat herpes zoster 5, 6, 7, 8
• Valaciclovir and famciclovir have been shown to be more effective than aciclovir in reducing the risk of pain associated with herpes zoster 5, 6, 8
• These medications are most effective when started within 72 hours of the onset of the rash 6, 7

Efficacy of Valaciclovir and Famciclovir

• Valaciclovir has been shown to be superior to famciclovir in reducing the risk of pain associated with herpes zoster 5, 8
• Valaciclovir has also been shown to accelerate the resolution of zoster-associated pain compared to famciclovir 8
• Both valaciclovir and famciclovir have been shown to be well-tolerated and effective in the treatment of herpes zoster 6, 8

Prescription Patterns and Patient Characteristics

• Antiviral therapy is often under-prescribed in patients with herpes zoster, even among those who are immunosuppressed or older 9
• Patient characteristics such as age, sex, and socioeconomic status can influence the likelihood of receiving antiviral therapy for herpes zoster 9

Pain Management

• Herpes zoster can cause significant pain, which can be managed with antiviral medications, tricyclic antidepressants, antiseizure drugs, opioids, and topical analgesics 7
• Prevention of herpes zoster through vaccination is preferable to treatment 7