What is the recommended treatment for shingles?

Shingles Treatment Recommendations

For shingles (herpes zoster), valacyclovir 1 gram three times daily for 7 days is the recommended first-line treatment, which should be initiated at the earliest sign or symptom of herpes zoster and within 48 hours of rash onset for maximum effectiveness. 1

Antiviral Medication Options

First-line Treatment:

• Valacyclovir: 1 gram orally 3 times daily for 7 days 1
  • Most effective when started within 48 hours of rash onset
  • Provides faster resolution of zoster-associated pain compared to acyclovir 2

Alternative Antiviral Options:

• Famciclovir: 500 mg orally 3 times daily for 7 days 3, 4

  • Similar efficacy to valacyclovir in speeding resolution of acute rash and shortening postherpetic neuralgia duration 2

• Acyclovir: 800 mg orally 5 times daily for 7 days 5, 6

  • Less convenient dosing schedule
  • Lower bioavailability compared to valacyclovir 2

Treatment Considerations

Timing of Treatment:

• Initiate treatment at the earliest sign or symptom of herpes zoster 1, 3
• Ideally within 72 hours of rash onset 5, 7
• Some benefit may still be obtained when starting treatment after 72 hours in certain cases 2

Special Populations:

• Patients with severe cases: Consider intravenous acyclovir 5-10 mg/kg body weight every 8 hours for 5-7 days 8

• Renal Impairment: Dose adjustments required 8, 1

  Creatinine Clearance	Valacyclovir Dosing Adjustment
  ≥50 mL/min	No adjustment needed
  10-29 mL/min	1 gram every 24 hours
  <10 mL/min	500 mg every 24 hours

Ocular Involvement:

• Patients with herpes zoster ophthalmicus should be referred to an ophthalmologist 5, 7
• Antiviral therapy remains important for these patients 2

Management of Complications

Postherpetic Neuralgia:

Postherpetic neuralgia (PHN) occurs in approximately 20% of patients with herpes zoster 7. Treatment options include:

• First-line options:

  • Gabapentin or pregabalin 7
  • Tricyclic antidepressants (e.g., amitriptyline) 5, 7

• Topical treatments:

  • Lidocaine patches 5, 7
  • Capsaicin 5, 7

• For severe pain:

  • Opioid analgesics may be necessary 5
  • Nerve blocks in selected patients 5

Patient Education and Monitoring

• Advise patients to keep the rash clean and dry to prevent secondary bacterial infection
• Explain that the rash typically progresses to clear vesicles that become cloudy and crust over in 7-10 days 7
• Inform patients that pain may persist after the rash resolves (postherpetic neuralgia)
• Follow up until complete resolution of lesions 8
• Monitor for complications such as secondary bacterial infection 8

Prevention

• Zoster vaccine is recommended for adults 60 years and older to decrease the incidence of herpes zoster 7
• The vaccine is approved for adults 50 years and older but specifically recommended by CDC for those 60+ 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 duration: Using shorter courses of antivirals than recommended
• Overlooking renal function: Not adjusting doses in patients with renal impairment