What is the recommended treatment for shingles?

Shingles Treatment

For herpes zoster (shingles), the recommended treatment is valacyclovir 1 gram three times daily for 7 days, initiated within 48 hours of rash onset for optimal effectiveness. 1

First-Line Antiviral Therapy

• Valacyclovir: 1 gram orally three times daily for 7 days 1
• Alternatives:
  • Acyclovir: 800 mg orally 5 times daily for 7 days 2, 3
  • Famciclovir: 500 mg orally three times daily for 7 days 4

Antiviral therapy is most effective when started within 72 hours of rash onset, but ideally within 48 hours 1, 2. However, treatment may still be beneficial when initiated later, particularly in patients with new vesicle formation, complications, or severe pain 4.

Clinical Presentation and Diagnosis

Shingles typically presents with:

• Prodromal symptoms: burning pain, tingling, or itching in a dermatomal distribution for 2-3 days
• Unilateral maculopapular rash that evolves into clear vesicles
• Vesicles that become cloudy and crust over within 7-10 days
• Rash confined to a single dermatome 5

Treatment Goals

1. Reduce acute pain
2. Accelerate rash healing
3. Prevent complications, particularly postherpetic neuralgia (PHN)

Pain Management

For pain associated with acute herpes zoster:

• Mild pain: Acetaminophen or NSAIDs
• Moderate to severe pain: Short-term opioid analgesics may be necessary
• Neuropathic pain:
  • Gabapentin or pregabalin
  • Tricyclic antidepressants (e.g., amitriptyline, nortriptyline)
  • Topical lidocaine patches or capsaicin 5

Special Considerations

Immunocompromised Patients

• More aggressive treatment may be warranted
• Consider IV acyclovir for severe cases or disseminated zoster 6

Ophthalmic Zoster

• Requires prompt referral to an ophthalmologist
• May require additional topical treatments 2

Postherpetic Neuralgia Prevention

• Despite early hopes, evidence suggests that antiviral therapy alone has limited effect on preventing PHN 7
• Consider adjunctive therapies for patients at high risk of PHN (elderly, severe acute pain, severe rash) 5

Corticosteroid Use

The addition of corticosteroids to antiviral therapy remains controversial:

• May provide modest benefits in reducing acute pain and accelerating rash healing
• Does not significantly reduce the incidence of postherpetic neuralgia
• Consider only in patients without contraindications to steroid use 3

Prevention

• Zoster vaccine is recommended for adults 60 years and older to reduce the incidence of herpes zoster 5
• No preventive measures are currently available once shingles has developed 6

Common Pitfalls to Avoid

1. Delayed treatment: Starting antivirals after 72 hours significantly reduces effectiveness
2. Inadequate pain management: Underestimating the severity of acute zoster pain
3. Missing ophthalmic involvement: Failing to recognize and refer cases with eye involvement
4. Overuse of steroids: Using corticosteroids in patients with contraindications
5. Insufficient follow-up: Not monitoring for development of postherpetic neuralgia

Early recognition and prompt initiation of antiviral therapy remain the cornerstones of effective shingles management.