What is the recommended workup and treatment for a patient presenting with shingles?

From the Guidelines

The recommended workup for shingles (herpes zoster) includes clinical diagnosis based on the characteristic unilateral, dermatomal vesicular rash, often preceded by pain or tingling, and treatment should begin as soon as possible, ideally within 72 hours of rash onset, with first-line therapy being oral antiviral medication. The treatment options include valacyclovir 1000mg three times daily for 7 days, famciclovir 500mg three times daily for 7 days, or acyclovir 800mg five times daily for 7-10 days, with valacyclovir and famciclovir being preferred due to better bioavailability and simpler dosing 1. Pain management is essential, typically with acetaminophen, NSAIDs, or in severe cases, short-term opioids. For patients over 50 or immunocompromised individuals, treatment is particularly important as they face higher risks of complications. Some key points to consider in the management of shingles include:

• Keeping the rash clean and covered to prevent viral transmission to susceptible individuals (pregnant women, immunocompromised people, and those without chickenpox history) 1.
• Monitoring for complications such as postherpetic neuralgia, bacterial superinfection, or ocular involvement (especially with V1 distribution), which may require specialty referral 1.
• The use of antivirals, which work by inhibiting viral DNA synthesis, reducing viral shedding, accelerating healing, and decreasing the risk of postherpetic neuralgia 1. It's also important to note that while there are various treatment options available, the most effective approach is often a combination of antiviral medication and pain management, tailored to the individual patient's needs and medical history 1.

From the Research

Shingles Workup and Treatment

• The recommended workup for a patient presenting with shingles includes a clinical diagnosis based on the distinctive, painful vesicular rash appearing in a unilateral, dermatomal distribution 2.
• Laboratory testing, such as polymerase chain reaction, can confirm atypical cases 2.
• Treatment with antiviral medications, such as acyclovir, famciclovir, or valacyclovir, can decrease the duration of the rash and reduce the risk of postherpetic neuralgia 3, 4, 5.
• Adjunct medications, including opioid analgesics, tricyclic antidepressants, or corticosteroids, may relieve the pain associated with acute herpes zoster 2.

Antiviral Therapy

• Oral antiviral agents, such as acyclovir, valacyclovir, and famciclovir, are the most important therapeutic keystone in the treatment of herpes zoster 5.
• Valacyclovir 1.5 g twice daily has been shown to be safe and effective for the treatment of uncomplicated herpes zoster in immunocompetent patients over 18 years of age 4.
• Antiviral therapy should be instituted promptly in immunosuppressed patients to reduce the incidence of cutaneous and visceral dissemination 6.

Pain Management

• Postherpetic neuralgia can last from 30 days to more than six months after the lesions have healed 2.
• Evidence supports treating postherpetic neuralgia with tricyclic antidepressants, gabapentin, pregabalin, long-acting opioids, or tramadol 2.
• Moderate evidence supports the use of capsaicin cream or a lidocaine patch as a second-line agent for postherpetic neuralgia 2.

Prevention

• Immunization to prevent herpes zoster and postherpetic neuralgia is recommended for most adults 60 years and older 2.
• The varicella zoster vaccine may cause shingles to be an uncommon and/or mild disease by the mid twenty-first century 3.