From the Guidelines
Treatment for varicella zoster shingles should involve antiviral medications, such as oral acyclovir, valacyclovir, or famciclovir, started within 72 hours of rash onset to reduce the severity of acute pain and accelerate cutaneous healing, as recommended by the most recent guidelines 1. The first-line treatment options include oral acyclovir (800 mg five times daily for 7-10 days), valacyclovir (1000 mg three times daily for 7 days), or famciclovir (500 mg three times daily for 7 days), with valacyclovir and famciclovir generally preferred due to better bioavailability and simpler dosing schedules.
- For severe cases or immunocompromised patients, intravenous acyclovir (10 mg/kg every 8 hours for 7-10 days) may be necessary, as it remains the treatment of choice for VZV infections in compromised hosts 1.
- Pain management is crucial and may include:
- Acetaminophen
- NSAIDs
- Gabapentin (300-1200 mg three times daily)
- Pregabalin (75-150 mg twice daily)
- Tricyclic antidepressants like amitriptyline (10-25 mg at bedtime)
- Topical lidocaine patches can provide localized relief.
- Corticosteroids (prednisone 60 mg daily for 7 days, then tapered over 2 weeks) may be added for severe pain or facial involvement. Patients should keep the rash clean and covered to prevent transmission to those who haven't had chickenpox. Early treatment reduces the risk of postherpetic neuralgia, which is persistent pain after the rash heals, particularly common in older adults, as noted in earlier studies 1.
From the FDA Drug Label
Herpes Zoster Infections : Acyclovir tablets is indicated for the acute treatment of herpes zoster (shingles). Herpes zoster (shingles) in immunocompetent adults. Herpes zoster (shingles)
The treatment for varicella zoster shingles includes:
- Acyclovir (PO): indicated for the acute treatment of herpes zoster (shingles) 2
- Valacyclovir (PO): indicated for the treatment of herpes zoster (shingles) in immunocompetent adults 3
- Famciclovir (PO): indicated for the treatment of herpes zoster (shingles) 4
From the Research
Treatment Options for Varicella Zoster Shingles
- Valacyclovir is an effective treatment for herpes zoster, with studies showing it can accelerate the resolution of the rash and associated pain, and reduce the duration of postherpetic neuralgia 5, 6, 7.
- The recommended dosage of valacyclovir for the treatment of herpes zoster is 1,000 mg three times daily for 7 days 6, 8.
- Twice-daily dosing of valacyclovir may be as effective as three times daily dosing, and may help increase patient compliance 5.
- Combination therapy with valacyclovir, methylprednisolone, and pregabalin may be more effective than valacyclovir alone in managing acute herpes zoster neuralgia 9.
- Other antiviral agents, such as acyclovir and famciclovir, may also be effective in treating herpes zoster, but valacyclovir has been shown to be more effective in some studies 6, 8, 7.
Efficacy and Safety of Treatment Options
- Valacyclovir has been shown to be safe and effective in the treatment of herpes zoster, with a low incidence of adverse effects 5, 6, 7.
- The most common adverse effects of valacyclovir are nausea and headache 6.
- Combination therapy with valacyclovir, methylprednisolone, and pregabalin has been shown to be safe and effective, with no significant increase in adverse effects 9.
- The efficacy and safety of different doses of antiviral agents in the treatment of herpes zoster have been evaluated in a meta-analysis, which found that 800 mg of acyclovir five times daily and 900-1,000 mg of valacyclovir three times daily are better choices for the treatment of herpes zoster 8.