What is the recommended treatment for shingles?

Treatment of Shingles (Herpes Zoster)

The recommended treatment for shingles 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

Antiviral therapy is the cornerstone of shingles treatment and should be initiated as soon as possible:

• Valacyclovir (preferred): 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

Valacyclovir is often preferred due to its convenient dosing schedule and superior bioavailability compared to acyclovir 4. Research has shown that valacyclovir is at least as effective as acyclovir in controlling acute symptoms of herpes zoster and significantly faster at alleviating zoster-associated pain and postherpetic neuralgia 4.

Timing of Treatment

Early treatment is crucial for optimal outcomes:

• Initiate therapy at the earliest sign or symptom of herpes zoster 1
• Most effective when started within 48 hours of rash onset 1
• Treatment may still provide benefit when started up to 72 hours after rash onset 4

Special Populations

Immunocompromised Patients

• Higher doses or longer treatment duration may be required
• Close monitoring for complications is essential

Renal Impairment

Dose adjustments are required for patients with renal impairment:

Valacyclovir dosing for renal impairment 5:

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

Complications and Their Management

Postherpetic Neuralgia (PHN)

The most common complication, occurring in approximately 20% of patients 6. Management options include:

• First-line: Gabapentin or pregabalin 6
• Second-line: Tricyclic antidepressants (e.g., amitriptyline) 6
• Topical treatments: Lidocaine patches or capsaicin 6

Ophthalmic Involvement

• Herpes zoster ophthalmicus requires prompt referral to an ophthalmologist 3
• Continue systemic antiviral therapy

Patient Education and Monitoring

• Assess treatment response within 72 hours and follow up until complete resolution of lesions 5
• Monitor for complications such as secondary bacterial infection
• Patients should be counseled about the natural history of the disease and potential for recurrent episodes
• Ensure adequate hydration during treatment, especially with IV acyclovir, to prevent renal complications 5

Prevention

• Vaccination against varicella zoster virus is recommended for adults 60 years and older to decrease the incidence of herpes zoster 5, 6
• Vaccination is contraindicated in immunocompromised individuals 5

Common Pitfalls to Avoid

1. Delayed treatment initiation: Starting antivirals after 72 hours significantly reduces their effectiveness
2. Inadequate pain management: PHN can be debilitating and requires aggressive treatment
3. Missing ophthalmic involvement: Always assess for eye involvement, which requires specialist care
4. Failing to adjust doses in renal impairment: Can lead to toxicity
5. Underestimating the importance of hydration: Particularly important with antiviral therapy to prevent renal complications