What is the treatment for a patient with shingles and no history of varicella (chickenpox)?

From the Guidelines

For a patient with shingles who has no history of varicella (chickenpox), the recommended treatment is antiviral therapy with oral valacyclovir or famciclovir in higher doses appropriate for VZV, for 7-10 days, as this approach has been shown to be effective in reducing the severity and duration of the illness 1.

Treatment Approach

The treatment should be started as soon as possible, ideally within 72 hours of rash onset.

• Oral valacyclovir (1000 mg three times daily) or famciclovir (500 mg three times daily) are recommended options for uncomplicated herpes zoster (typical dermatomal rash) 1.
• Pain management is also crucial and may include acetaminophen, NSAIDs, or in more severe cases, gabapentin, pregabalin, or tricyclic antidepressants for neuropathic pain.

Considerations

Even without a history of chickenpox, shingles indicates that the patient was previously infected with the varicella-zoster virus (VZV), possibly with a subclinical or unrecognized case of chickenpox 1.

• The virus remained dormant in sensory nerve ganglia until reactivating as shingles.
• Patients should be advised to keep the rash covered to prevent transmission to individuals who have not had chickenpox or the varicella vaccine, particularly pregnant women, newborns, and immunocompromised individuals, as the virus can cause primary varicella infection in these susceptible contacts.

Special Considerations for Immunocompromised Patients

For immunocompromised patients, antiviral therapy is recommended for herpes zoster, and treatment for complicated cases (including multi-dermatomal, ophthalmic, visceral, or disseminated) is intravenous acyclovir 1.

• If immunosuppression has been withheld, it may be reasonable to restart after the patient has commenced anti-VZV therapy and the skin vesicles have resolved.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Acute Treatment of Herpes Zoster: 800 mg every 4 hours orally, 5 times daily for 7 to 10 days. Herpes Zoster Infections : Acyclovir tablets is indicated for the acute treatment of herpes zoster (shingles).

The treatment for a patient with shingles and no history of varicella (chickenpox) is 800 mg of acyclovir every 4 hours orally, 5 times daily for 7 to 10 days. This is based on the indication for acute treatment of herpes zoster (shingles) 2 and the approved use of acyclovir for herpes zoster infections 2.

• Key points:
  • Dose: 800 mg
  • Frequency: every 4 hours
  • Duration: 7 to 10 days
  • Administration: orally, 5 times daily

From the Research

Treatment for Shingles with No History of Varicella

• The treatment for a patient with shingles and no history of varicella (chickenpox) is primarily focused on managing symptoms and reducing the risk of complications 3.
• Antiviral therapy, such as acyclovir or valaciclovir, is effective in treating acute herpes zoster and can help alleviate zoster-associated pain and postherpetic neuralgia 4.
• Valaciclovir, in particular, has been shown to be at least as effective as aciclovir in controlling the symptoms of acute herpes zoster and can be used as a first-line therapy for immunocompetent patients with herpes zoster 4.
• In some cases, treatment with gabapentin and antiviral concomitantly as soon as the rash develops may reduce the severity of complications, but more research is needed to confirm this 5.
• For patients with postherpetic neuralgia, antiviral therapy such as intravenous acyclovir followed by oral valacyclovir may help reduce pain, especially in patients with chronic VZV ganglionitis 6, 7.

Patient Characteristics and Treatment Efficacy

• Patient characteristics, such as pathophysiology and serum vitamin D levels, may affect the analgesic efficacy of antiviral therapy in postherpetic neuralgia 7.
• Patients with chronic VZV ganglionitis may respond better to antiviral therapy, while those with negative VZV-DNA or IgM may not benefit from this treatment 7.
• Vitamin D supplementation may improve the antiviral efficacy on postherpetic neuralgia, especially in patients with vitamin D deficiency 7.

Treatment Approach

• The treatment approach for shingles with no history of varicella should be individualized and based on the patient's specific needs and characteristics 3, 4, 5, 6, 7.
• A comprehensive treatment plan may include antiviral therapy, pain management, and lifestyle modifications to reduce the risk of complications and improve quality of life 3, 4, 5, 6, 7.