From the Guidelines
The treatment for a patient presenting with the start of a shingles rash involves prompt antiviral therapy, ideally within 72 hours of rash onset, with first-line medications including valacyclovir, famciclovir, or acyclovir.
Key Considerations
- The goal of treatment is to accelerate the rate of cutaneous healing, reduce the severity of acute pain, and prevent postherpetic neuralgia, a potentially debilitating complication of shingles characterized by persistent pain after the rash resolves 1.
- Valacyclovir and famciclovir are generally preferred due to better bioavailability and simpler dosing schedules.
- Pain management is also essential, using acetaminophen or NSAIDs for mild pain, or potentially gabapentin, pregabalin, or tricyclic antidepressants for more severe pain.
- Topical calamine lotion or cool compresses may provide symptomatic relief.
- Patients should keep the rash clean and dry to prevent bacterial superinfection.
- Antiviral therapy works by inhibiting viral DNA synthesis, reducing viral shedding, accelerating healing, and decreasing the severity and duration of acute pain.
Treatment Recommendations
- Valacyclovir: 1,000 mg three times daily for 7 days
- Famciclovir: 500 mg three times daily for 7 days
- Acyclovir: 800 mg five times daily for 7-10 days
- Treatment should be continued at least until all lesions have scabbed, as recommended by the KDIGO clinical practice guideline for the care of kidney transplant recipients 1.
- Immunocompromised patients may require longer treatment courses or intravenous therapy.
From the FDA Drug Label
Herpes Zoster The recommended dosage of VALTREX for treatment of herpes zoster is 1 gram 3 times daily for 7 days Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of the onset of rash.
The treatment for a patient presenting with the start of a shingles (herpes zoster) rash is valacyclovir (PO), with a recommended dosage of 1 gram 3 times daily for 7 days. Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of the onset of rash 2.
Alternatively, famciclovir (PO) may also be used to treat herpes zoster, but the exact dosage is not specified in the provided drug label. However, it is advised to initiate treatment as soon as possible after a diagnosis of herpes zoster, and there are no data on treatment initiated more than 72 hours after onset of zoster rash 3 3.
From the Research
Treatment for Shingles Rash
The treatment for a patient presenting with the start of a shingles (herpes zoster) rash typically involves antiviral medications.
- The antiviral medications most commonly used are acyclovir, famciclovir, and valacyclovir 4, 5, 6, 7.
- These medications are most effective when started within 72 hours after the onset of the rash 4, 7.
- The addition of an orally administered corticosteroid can provide modest benefits in reducing the pain of herpes zoster and the incidence of postherpetic neuralgia 4.
Management of Pain
- Patients with postherpetic neuralgia may require narcotics for adequate pain control 4.
- Tricyclic antidepressants or anticonvulsants, often given in low dosages, may help to control neuropathic pain 4.
- Capsaicin, lidocaine patches, and nerve blocks can also be used in selected patients 4.
Special Considerations
- Ocular involvement in herpes zoster can lead to rare but serious complications and generally merits referral to an ophthalmologist 4.
- Immunocompromised patients may require more aggressive treatment, including intravenous antiviral therapy 5, 7.
- The varicella zoster vaccine may help prevent shingles in the future, but it is not a treatment for current cases 6.