What is the recommended treatment for shingles?

Treatment for Shingles

The recommended treatment for shingles (herpes zoster) is valacyclovir 1 gram orally three times daily for 7 days, initiated at the earliest sign or symptom of herpes zoster. 1, 2

First-Line Antiviral Therapy

Antiviral therapy should be started as soon as possible, ideally within 48 hours of rash onset:

• Valacyclovir: 1 gram three times daily for 7 days 1, 2
• Famciclovir: 500 mg three times daily for 7 days 3
• Acyclovir: 800 mg five times daily for 7-10 days 1

Valacyclovir and famciclovir are preferred over acyclovir due to their more convenient dosing schedule and better bioavailability 4.

Special Clinical Scenarios

Severe or Complicated Shingles

For complicated shingles (multi-dermatomal, ophthalmic, visceral, or disseminated):

• Intravenous acyclovir is recommended 1
• Consider hospitalization for severe cases

Immunocompromised Patients

• Antiviral therapy is strongly recommended for all immunocompromised patients 1
• Consider intravenous acyclovir for severe cases 1
• Immunosuppressive therapy should be discontinued in severe cases of disseminated VZV 1

Ophthalmic Zoster

• Same antiviral dosing regimen applies
• Urgent ophthalmology consultation is strongly recommended 1

Timing of Treatment

While antivirals are most effective when started within 72 hours of rash onset, observational data suggests that valacyclovir may still provide benefit when started later 4. However, treatment should be initiated as early as possible for maximum effectiveness.

Pain Management

Acute pain management is an important component of shingles treatment:

• NSAIDs or acetaminophen for mild pain
• Opioid analgesics may be necessary for severe pain
• Gabapentin or pregabalin can be added for neuropathic pain components

Prevention of Postherpetic Neuralgia

Early antiviral therapy helps reduce the risk of postherpetic neuralgia (PHN) 5. Valacyclovir has been shown to alleviate zoster-associated pain and PHN significantly faster than acyclovir 4.

Corticosteroids

The addition of corticosteroids to antiviral therapy may provide modest benefits in reducing acute pain but is associated with increased risk of adverse effects, especially in older adults 6, 7. Corticosteroids should be used cautiously and are not routinely recommended for all patients.

Monitoring and Follow-up

• Monitor for adequate pain control
• Ensure lesions begin to resolve within 7-10 days
• Watch for potential complications including secondary bacterial infection
• No laboratory monitoring is needed unless the patient has substantial renal impairment 1

Dose Adjustments for Renal Impairment

For valacyclovir, adjust dosing based on creatinine clearance:

• ≥50 mL/min: No adjustment needed
• 30-49 mL/min: No adjustment needed
• 10-29 mL/min: 1 gram every 24 hours
• <10 mL/min: 500 mg every 24 hours 1

Remember that early treatment is crucial for reducing the severity and duration of shingles, as well as decreasing the risk of complications such as postherpetic neuralgia.