What is the recommended treatment for shingles?

Shingles Treatment

The recommended treatment for shingles (herpes zoster) is oral antiviral therapy with valacyclovir 1 gram three times daily for 7 days, initiated within 72 hours of rash onset for maximum effectiveness. 1

Initial Assessment and Diagnosis

• Shingles presents as a unilateral, dermatomal rash with vesicular lesions
• Prodromal symptoms often precede the rash by 2-3 days, including:
  • Burning pain
  • Tingling
  • Itching
  • Abnormal skin sensations in the affected dermatome

Antiviral Therapy Options

First-line Treatment

• Valacyclovir: 1 gram orally three times daily for 7 days 1, 2
  • Most convenient dosing schedule
  • Better bioavailability than acyclovir
  • Significantly faster alleviation of zoster-associated pain compared to acyclovir 3

Alternative Options

• Famciclovir: 500 mg orally three times daily for 7 days 1, 4
• Acyclovir: 800 mg orally five times daily for 7 days 5

Timing of Treatment

• Initiate treatment at the earliest sign or symptom of herpes zoster 1, 4
• Most effective when started within 72 hours of rash onset 5
• However, treatment may still be beneficial when started after 72 hours, especially in patients with ongoing new vesicle formation or immunocompromised status 3

Special Considerations

Immunocompromised Patients

• Antiviral therapy is strongly recommended for all immunocompromised patients 6
• For severe cases or immunosuppressed patients:
  • Consider intravenous acyclovir 1
  • Immunosuppressive therapy should be discontinued in severe cases of varicella infection and disseminated VZV 6

Complicated Shingles

• For complicated shingles (multi-dermatomal, ophthalmic, visceral, or disseminated):
  • Intravenous acyclovir is recommended 6
  • Ophthalmology consultation is required for ophthalmic involvement 1

Renal Impairment

• Dose adjustment required for valacyclovir in patients with renal impairment:
  • For creatinine clearance 10-29 mL/min: 1 gram every 24 hours 1
  • For creatinine clearance <10 mL/min: 500 mg every 24 hours 1

Pain Management

• Acute pain management:

  • NSAIDs or acetaminophen for mild pain
  • Consider opioid analgesics for moderate to severe pain
  • Addition of a neuroactive agent (e.g., amitriptyline) can be helpful 7

• For postherpetic neuralgia (pain persisting >90 days after rash):

  • Tricyclic antidepressants (amitriptyline)
  • Anticonvulsants (gabapentin, pregabalin)
  • Topical agents (lidocaine patches, capsaicin) 8, 5

Monitoring and Follow-up

• No laboratory monitoring is needed in patients with normal renal function 1
• Treatment failure should be suspected if lesions do not begin to resolve within 7-10 days 1
• Monitor for potential adverse effects:
  • Nausea, headache (common with valacyclovir) 1
  • Neurological symptoms (confusion, agitation, hallucinations) which may indicate neurotoxicity 1

Prevention

• Varicella zoster virus vaccine is recommended for adults 60 years and older to decrease the incidence of herpes zoster 5
• Vaccination is contraindicated in immunocompromised individuals 6

Clinical Pearls

• Early treatment is crucial for reducing the risk of postherpetic neuralgia
• The convenience of valacyclovir's three-times-daily dosing may improve adherence compared to acyclovir's five-times-daily regimen
• Acyclovir-resistant HSV can be treated with foscarnet 40 mg/kg IV three times daily 1
• Patients should be advised to avoid contact with individuals who have not had chickenpox or the varicella vaccine until lesions have crusted over