Shingles Treatment
For shingles (herpes zoster), 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 Options
Antiviral medications are the cornerstone of shingles treatment and should be started as soon as possible:
- 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 preferred over acyclovir due to their more convenient dosing schedules and better bioavailability 4. Studies have shown that valacyclovir alleviates zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 4.
Timing of Treatment
Treatment is most effective when initiated within 72 hours of rash onset 5. However, observational data suggests that starting valacyclovir even after 72 hours may still provide benefit in reducing zoster-associated pain 4.
Treatment Goals
Antiviral therapy for shingles aims to:
- Accelerate lesion healing
- Reduce viral shedding
- Decrease acute pain
- Reduce the duration and severity of postherpetic neuralgia 6
Special Populations
Immunocompromised Patients
HIV-infected patients who are susceptible to VZV should receive varicella zoster immune globulin (VZIG) within 96 hours after exposure to someone with chickenpox or shingles 7.
Ocular Involvement
Patients with zoster ophthalmicus (herpes zoster affecting the eye) should be referred to an ophthalmologist due to potential serious complications 3.
Management of Postherpetic Neuralgia
Postherpetic neuralgia (PHN) occurs in approximately 20% of patients with shingles 5. Treatment options include:
- First-line: Tricyclic antidepressants, gabapentin, or pregabalin 5
- Topical treatments: Lidocaine patches or capsaicin 5
- For severe pain: Narcotic analgesics may be required 3
Prevention
The varicella zoster virus vaccine is recommended for adults 60 years and older to decrease the incidence of herpes zoster, except in certain immunosuppressed patients 5. However, once shingles has developed, no preventive measures are currently available for recurrence 7.
Common Pitfalls to Avoid
- Delayed treatment: Starting antivirals after 72 hours significantly reduces their effectiveness
- Inadequate pain management: Underestimating the severity of acute and chronic pain
- Missing ocular involvement: Failing to recognize and refer cases with eye involvement
- Insufficient patient education: Not informing patients about the potential for postherpetic neuralgia
Early recognition and prompt initiation of antiviral therapy remain the most important factors in improving outcomes for patients with shingles.