From the Guidelines
The recommended treatment for herpes zoster (shingles) includes prompt initiation of antiviral therapy, ideally within 72 hours of rash onset, with oral valacyclovir or famciclovir being the preferred choices due to their better bioavailability and simpler dosing. According to the most recent guidelines 1, first-line medications for uncomplicated herpes zoster include oral valacyclovir or famciclovir in higher doses appropriate for VZV. The treatment should be prescribed within 72 hours of rash onset and should continue for a minimum of 7–10 days.
Pain management is essential and may include acetaminophen, NSAIDs, or in more severe cases, gabapentin (starting at 300 mg daily and titrating up), pregabalin, tricyclic antidepressants, or short-term opioids. Topical treatments like lidocaine patches or capsaicin cream can provide localized relief. The affected area should be kept clean and covered if weeping to prevent viral transmission, particularly around immunocompromised individuals, pregnant women, or those without chickenpox immunity.
Some key points to consider in management include:
- Monitoring for complications such as secondary bacterial infections, postherpetic neuralgia, or ophthalmic involvement (which requires urgent ophthalmology referral) 1.
- Early treatment reduces viral replication, shortens the duration of symptoms, decreases the risk of postherpetic neuralgia, and limits the spread of lesions.
- Immunocompromised patients may require intravenous antivirals and closer monitoring, with treatment guidelines suggesting intravenous acyclovir for complicated cases, including multi-dermatomal, ophthalmic, visceral, or disseminated HZ 1.
It's also important to note that while older studies like 1 support the use of acyclovir, famciclovir, and valacyclovir, the most recent and highest quality evidence 1 guides the current recommendations, emphasizing the importance of prompt antiviral therapy and appropriate pain management to improve outcomes in patients with herpes zoster.
From the FDA Drug Label
The recommended dosage of valacyclovir hydrochloride 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 recommended treatment for a patient with symptoms concerning for herpes zoster (shingles) rash is valacyclovir 1 gram three times daily for 7 days. Therapy should be initiated as soon as possible, ideally within 48 hours of the onset of rash.
- Key points:
- Initiate treatment at the earliest sign or symptom of herpes zoster
- Most effective when started within 48 hours of the onset of rash
- Dosage: 1 gram three times daily for 7 days
- Valacyclovir is the recommended medication 2
Alternatively, famciclovir may also be considered for the treatment of herpes zoster.
- Key points:
- Patients should be advised to initiate treatment as soon as possible after a diagnosis of herpes zoster
- There are no data on treatment initiated more than 72 hours after onset of zoster rash
- Famciclovir tablets are a prescription antiviral medicine used to treat shingles (herpes zoster) in adults 3
From the Research
Treatment and Management of Herpes Zoster (Shingles) Rash
The recommended treatment and management for a patient with symptoms concerning for herpes zoster (shingles) rash include:
- Antiviral medications such as acyclovir, famciclovir, and valacyclovir, which are most effective when started within 72 hours after the onset of the rash 4, 5, 6
- The addition of an orally administered corticosteroid can provide modest benefits in reducing the pain of herpes zoster and the incidence of postherpetic neuralgia, but may be associated with an increased risk of serious adverse effects, especially among older adults 4, 7, 8
- Treatment of postherpetic neuralgia may include:
- Nonpharmacologic approaches may be considered for individuals with treatment-refractory postherpetic neuralgia, and a pain-management specialist should be consulted 8
- Ocular involvement in herpes zoster can lead to rare but serious complications and generally merits referral to an ophthalmologist 4
Antiviral Medication Regimens
- Valacyclovir 1.5 g twice daily for 7 days is safe and effective for the treatment of uncomplicated herpes zoster in immunocompetent patients over 18 years of age 5
- Valacyclovir 1000 mg 3 times daily for 7 days is at least as effective as acyclovir 800 mg 5 times daily for 7 days in controlling the symptoms of acute herpes zoster 6
- Acyclovir 800 mg orally 5 times daily for 7 days is a commonly used regimen for the treatment of herpes zoster 4, 7, 6