What is the recommended treatment for shingles?

Shingles Treatment

For shingles (herpes zoster), the recommended treatment is valacyclovir 1 gram three times daily for 7 days, initiated at the earliest sign or symptom of herpes zoster and ideally within 48 hours of rash onset. 1

First-Line Antiviral Therapy Options

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

Treatment Timing and Efficacy

Antiviral therapy is most effective when started within 72 hours after the onset of the rash 3. However, treatment may still be beneficial when initiated later than 72 hours after rash onset, particularly in patients who continue to have new vesicle formation or who are at high risk for complications 4.

Clinical Considerations

Patient Presentation

• Prodromal symptoms: burning pain, tingling, or itching in the affected dermatome 2-3 days before rash appears 5
• Classic presentation: unilateral, dermatomal, maculopapular rash that progresses to vesicles that crust over in 7-10 days 5

Medication Selection Factors

• Valacyclovir and famciclovir are preferred over acyclovir due to:
  • Better bioavailability 4
  • Less frequent dosing (3 times daily vs 5 times daily) 3
  • Improved compliance due to simplified dosing regimen

Special Populations

Renal Impairment

Dose adjustments are required for patients with renal impairment:

Valacyclovir dosing for herpes zoster in renal impairment 1:

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

Immunocompromised Patients

Immunocompromised patients are at higher risk for disseminated disease and complications. They may require:

• Higher doses of antiviral therapy
• Longer duration of treatment
• Closer monitoring for complications 6

Prevention of Complications

Postherpetic Neuralgia (PHN)

• Most common complication, occurring in approximately 20% of patients 5
• Early antiviral therapy reduces the risk and duration of PHN 7
• Valacyclovir has been shown to alleviate zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 4

Ocular Involvement

• Herpes zoster ophthalmicus requires prompt referral to an ophthalmologist 3
• Antiviral therapy should be initiated immediately to prevent vision-threatening complications

Adjunctive Therapies

Pain Management

For acute pain during shingles:

• Acetaminophen or NSAIDs for mild pain
• Short-term opioids may be necessary for severe pain

Role of Corticosteroids

• The addition of corticosteroids to antiviral therapy provides modest benefits in reducing acute pain but does not significantly reduce the incidence of postherpetic neuralgia 8
• Corticosteroids should be used with caution and are generally not recommended as routine therapy for all patients with herpes zoster

Prevention

• Zoster vaccine is recommended for adults aged 60 years and older to reduce the incidence of herpes zoster and postherpetic neuralgia 5
• Vaccination is contraindicated in immunocompromised individuals 5

Common Pitfalls

• Delayed treatment: Initiating antiviral therapy beyond 72 hours after rash onset reduces efficacy
• Inadequate pain management: Underestimating the severity of acute zoster pain
• Missing ocular involvement: Failing to recognize and promptly refer patients with herpes zoster ophthalmicus
• Inappropriate corticosteroid use: Using corticosteroids in patients with contraindications such as uncontrolled diabetes or immunosuppression