What is the treatment for Herpes Zoster (shingles)?

From the Guidelines

Varicella zoster shingles is best treated with antiviral medications, specifically acyclovir or famciclovir, started within 72 hours of rash onset, as they have been shown to accelerate cutaneous healing and reduce the severity of acute pain in adults 1. When treating varicella zoster shingles, the following options are available:

• Oral acyclovir 800mg five times daily for 7-10 days
• Oral famciclovir 500mg three times daily for 7 days These medications have similar efficacy when administered within 72 hours of rash onset, as demonstrated in studies 1. For pain management, the following options can be considered:
• Acetaminophen or NSAIDs for initial pain relief
• Gabapentin or pregabalin for persistent pain, with gabapentin starting at 300mg daily and titrating up, and pregabalin starting at 75mg twice daily
• Topical lidocaine patches or capsaicin cream for localized relief It is essential to keep the rash clean and covered to prevent spreading the virus to others who haven't had chickenpox, and patients should avoid contact with pregnant women, newborns, and immunocompromised individuals until lesions crust over 1. In severe cases or for immunocompromised patients, intravenous acyclovir 10mg/kg every 8 hours may be required. Antiviral therapy has been shown to reduce viral shedding, speed healing, and decrease the risk of postherpetic neuralgia, which is persistent pain after the rash heals, particularly common in older adults 1.

From the FDA Drug Label

Herpes zoster (shingles):Famciclovir tablets are indicated for the treatment of herpes zoster in adult patients. The efficacy of famciclovir tablets when initiated more than 72 hours after onset of rash has not been established. Herpes Zoster VALTREX is indicated for the treatment of herpes zoster (shingles) in immunocompetent adults. The efficacy of VALTREX when initiated more than 72 hours after the onset of rash and the efficacy and safety of VALTREX for treatment of disseminated herpes zoster have not been established. Herpes Zoster Infections : Acyclovir tablets is indicated for the acute treatment of herpes zoster (shingles).

Treatment Options:

• Famciclovir: 500 mg every 8 hours for 7 days, initiate as soon as herpes zoster is diagnosed 2
• Valacyclovir: dosage not specified in the label for herpes zoster, but indicated for treatment of herpes zoster in immunocompetent adults 3
• Acyclovir: dosage not specified in the label for herpes zoster, but indicated for acute treatment of herpes zoster (shingles) 4

Key Considerations:

• Initiate treatment as soon as possible, ideally within 72 hours of rash onset
• Famciclovir has a specified dosage and treatment duration, while valacyclovir and acyclovir do not have specified dosages in the provided labels.

From the Research

Treatment Options for Varicella Zoster Shingles

• Antiviral therapy is effective in treating acute varicella and herpes zoster, with options including aciclovir, valaciclovir, and famciclovir 5, 6, 7, 8
• Valaciclovir has been shown to be at least as effective as aciclovir in controlling symptoms of acute herpes zoster, and may alleviate zoster-associated pain and postherpetic neuralgia faster than aciclovir 5
• The recommended regimen for valaciclovir is 1000 mg 3 times daily for 7 days, which has been shown to be well tolerated with nausea and headache being the most commonly reported adverse events 5
• Gabapentin may be used concomitantly with antiviral therapy to reduce the severity of complications, but there is a lack of data showing its effectiveness in preventing postherpetic neuralgia 6
• Vaccination against varicella zoster virus is also an option, particularly for individuals over 50 years old, to reduce the risk of developing herpes zoster and postherpetic neuralgia 6, 7

Management of Postherpetic Neuralgia

• Postherpetic neuralgia is a common complication of herpes zoster, and can be difficult to manage 6, 9
• Antiviral therapy may not be effective in treating postherpetic neuralgia, with one study showing that 56 days of intravenous and oral acyclovir therapy had little or no effect on the clinical course of postherpetic neuralgia 9
• Other treatment options for postherpetic neuralgia may include gabapentin, but more research is needed to determine its effectiveness 6

Prevention and Vaccination

• Vaccination against varicella zoster virus can help prevent herpes zoster and postherpetic neuralgia, particularly in individuals over 50 years old 6, 7
• The varicella zoster vaccine has been shown to be effective in reducing the burden of illness caused by varicella zoster virus and the incidence of herpes zoster 6