What is the recommended management for shingles?

Shingles Management

The recommended management for shingles includes antiviral therapy with valacyclovir 1 gram three times daily for 7 days, initiated within 72 hours of rash onset for optimal effectiveness. 1, 2

Antiviral Therapy Options

First-line Treatment

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

Timing of Treatment

• Initiate therapy at the earliest sign or symptom of herpes zoster 2
• Most effective when started within 48-72 hours of rash onset 3, 4
• Recent evidence suggests benefit may still exist when started later than 72 hours after rash onset 4

Special Populations

Immunocompromised Patients

• Prompt antiviral therapy is critical to reduce risk of cutaneous and visceral dissemination 5
• For localized disease: oral valacyclovir, famciclovir, or acyclovir with close outpatient follow-up 5
• For disseminated disease: intravenous acyclovir 5
• For acyclovir-resistant cases: foscarnet is the drug of choice 5

HIV-Infected Patients

• No specific preventive measures are currently available for shingles in HIV-infected persons 6
• No drug has been proven to prevent recurrence of shingles in HIV-infected persons 6

Pain Management

• Adequate pain control is essential during acute phase and to prevent postherpetic neuralgia 3
• Options include:
  • Analgesics (may require narcotics for adequate pain control) 3
  • Tricyclic antidepressants or anticonvulsants in low dosages for neuropathic pain 3
  • Capsaicin, lidocaine patches, and nerve blocks for selected patients 3

Role of Corticosteroids

• Addition of oral corticosteroids provides modest benefits in reducing acute pain 3
• However, studies show only slight benefits of adding prednisolone to acyclovir therapy 7
• Corticosteroids do not significantly reduce the frequency of postherpetic neuralgia 7

Complications to Monitor

Postherpetic Neuralgia

• Persistent pain after resolution of rash, more common with increasing age 3
• Valacyclovir has been shown to alleviate zoster-associated pain and postherpetic neuralgia faster than acyclovir 4

Ocular Involvement

• Herpes zoster ophthalmicus requires prompt treatment and generally merits referral to an ophthalmologist 3
• Valacyclovir and acyclovir demonstrate similar efficacy for ocular complications 4

Prevention

• Vaccination is the most effective strategy for prevention of herpes zoster and postherpetic neuralgia 8
• The Shingles Prevention Study demonstrated effectiveness of vaccination in preventing herpes zoster 8

Common Pitfalls to Avoid

1. Delayed treatment: Initiating antiviral therapy beyond 72 hours significantly reduces effectiveness
2. Inadequate pain management: Underestimating the severity of acute pain and risk of postherpetic neuralgia
3. Missing ocular involvement: Failing to recognize and promptly refer cases with eye involvement
4. Inappropriate corticosteroid use: Overreliance on corticosteroids without recognizing their limited benefit
5. Insufficient monitoring: Failing to follow patients for development of postherpetic neuralgia

Early recognition and prompt initiation of antiviral therapy remain the cornerstones of effective shingles management to reduce acute symptoms and prevent complications.