What is the treatment for shingles involving multiple dermatomes?

From the Guidelines

Treatment for shingles involving multiple dermatomes requires prompt antiviral therapy with valacyclovir (1000 mg three times daily), famciclovir (500 mg three times daily), or acyclovir (800 mg five times daily) for 7-10 days, as recommended by the most recent guidelines 1. When shingles affects multiple dermatomes, hospitalization should be considered, especially for immunocompromised patients, as this presentation suggests a more severe infection with higher risk of complications. Key considerations in management include:

• Pain management with acetaminophen, NSAIDs, and in severe cases, opioids or gabapentin
• Topical treatments like lidocaine patches or calamine lotion for localized relief
• Intravenous acyclovir (10 mg/kg every 8 hours) for severe cases or immunocompromised patients
• Corticosteroids like prednisone (60 mg daily for 7 days followed by a taper) to reduce inflammation and pain in select patients without contraindications Treatment should begin within 72 hours of rash onset for maximum effectiveness, as antivirals work by inhibiting viral DNA replication 1. Close monitoring for dissemination to other organs is important, as multidermatomal shingles may indicate underlying immunosuppression that requires further evaluation. Infection control measures, including standard, airborne, and contact precautions, are crucial when managing patients with disseminated zoster or those who are immunocompromised 1.

From the Research

Treatment for Shingles Involving Multiple Dermatomes

• The treatment for shingles involving multiple dermatomes typically involves antiviral therapy, such as acyclovir, famciclovir, or valaciclovir, to reduce the severity and duration of the disease 2, 3.
• In immunocompromised patients, shingles can be more severe and may involve multiple dermatomes, requiring more aggressive treatment 2, 4.
• Famciclovir and valaciclovir have been shown to be effective in reducing the time to complete cessation of zoster-associated pain, including post-herpetic neuralgia, compared to acyclovir 3, 5.
• Corticosteroids may also be used in combination with antiviral therapy to reduce inflammation and pain, but their effectiveness in preventing post-herpetic neuralgia is not consistent 3.
• In cases of disseminated herpes zoster, involving multiple widely separated dermatomes, treatment may need to be more aggressive and individualized 4, 6.

Antiviral Therapy

• Acyclovir is typically taken 5 times daily for 7 days, while famciclovir is taken 3 times daily for 7 days 3.
• Valaciclovir, the L-valyl ester of aciclovir, has been shown to be more efficient and effective than aciclovir in shortening the duration of post-herpetic neuralgia 3.
• Famciclovir has been shown to be superior to valacyclovir in relieving acute pain of herpes zoster, especially in patients aged 50 years or older 5.

Special Considerations

• Immunocompromised patients, such as those with HIV infection, may require more aggressive treatment and closer monitoring due to the increased risk of complications and dissemination 2, 4.
• Pregnant women with shingles should be treated with antiviral therapy, but the risk of congenital abnormalities is low 2.
• The diagnosis of shingles is typically made by history and physical examination, but laboratory tests and virus isolation may be necessary in some cases 2.