What is the recommended treatment for shingles?

Treatment of Shingles (Herpes Zoster)

For patients with shingles, oral antiviral therapy with valacyclovir 1 gram three times daily for 7 days is the recommended treatment, which should be initiated within 72 hours of rash onset to reduce pain duration and accelerate healing. 1

First-Line Antiviral Options

Antiviral therapy is the cornerstone of shingles treatment and should be started as soon as possible after symptom onset:

• Valacyclovir: 1 gram orally 3 times daily for 7 days 1
• Famciclovir: 500 mg orally 3 times daily for 7 days 2
• Acyclovir: 800 mg orally 5 times daily for 7 days 3

Valacyclovir and famciclovir are generally preferred over acyclovir due to their simpler dosing schedules, which improves medication adherence. The less frequent dosing of valacyclovir (3 times daily) compared to acyclovir (5 times daily) has been shown to improve patient compliance while maintaining similar efficacy 4.

Treatment Algorithm

1. Initiate treatment immediately: Begin antiviral therapy within 72 hours of rash onset for maximum effectiveness
2. Choose appropriate antiviral:
   • First choice: Valacyclovir 1 g three times daily for 7 days
   • Alternative: Famciclovir 500 mg three times daily for 7 days
   • Alternative: Acyclovir 800 mg five times daily for 7 days
3. Monitor for healing: Treatment may be extended if healing is incomplete after 7-10 days 3

Special Considerations

Immunocompromised Patients

Immunocompromised patients may require higher doses and longer treatment courses:

• Consider increasing valacyclovir to 1 g three times daily for 10-14 days 4
• For severe cases, hospitalization and IV acyclovir (5-10 mg/kg every 8 hours) may be necessary 3

Severe Pain

For patients with significant pain:

• Add appropriate analgesics based on pain severity
• Consider early initiation of tricyclic antidepressants or anticonvulsants for neuropathic pain 5

Ophthalmic Involvement

• Herpes zoster affecting the ophthalmic branch of the trigeminal nerve requires urgent ophthalmology referral 5

Prevention of Postherpetic Neuralgia

Postherpetic neuralgia (PHN) is a common complication of shingles, particularly in older adults. Early antiviral therapy has been shown to reduce the risk and duration of PHN:

• Valacyclovir has been shown to accelerate the resolution of herpes zoster-associated pain compared to acyclovir (38 days vs. 51 days) 4
• Famciclovir recipients experienced resolution of PHN twice as fast as those receiving placebo, with a 3.5-month reduction in median duration of PHN for patients ≥50 years 2

Common Pitfalls to Avoid

1. Delayed treatment: Starting antivirals after 72 hours significantly reduces their effectiveness
2. Inadequate dosing: Using lower doses than recommended may lead to treatment failure
3. Poor adherence: Complex dosing schedules (especially with acyclovir) can lead to missed doses
4. Relying solely on topical treatments: Topical antivirals alone are insufficient for treating shingles
5. Failure to address pain: Pain management should be initiated concurrently with antiviral therapy

Early recognition and prompt initiation of appropriate antiviral therapy are crucial for reducing the acute symptoms of shingles and preventing long-term complications like postherpetic neuralgia.