Shingles Treatment
For shingles (herpes zoster), the recommended treatment is valacyclovir 1000 mg three times daily for 7 days, initiated at the earliest sign or symptom of shingles. 1, 2
First-Line Antiviral Therapy
Recommended Medications and Dosing
- Valacyclovir: 1000 mg three times daily for 7 days 1, 2
- Acyclovir: 800 mg five times daily for 7 days 1, 3
- Famciclovir: 500 mg three times daily for 7 days 1
Timing of Treatment
- Initiate treatment at the earliest sign or symptom of herpes zoster 2
- Treatment is most effective when started within 48 hours of rash onset 2, 3
- Some benefit may still be obtained when starting treatment after 72 hours, particularly for reducing zoster-associated pain 4
Special Populations
Immunocompromised Patients
- Continue treatment until complete healing of lesions 1
- For HIV-infected patients with CD4+ count ≥100 cells/mm³, use valacyclovir 500 mg twice daily 1
- Higher oral doses may be necessary for immunocompromised patients 1
Renal Impairment
Dose adjustments based on creatinine clearance:
Valacyclovir adjustments:
- ≥50 mL/min: No adjustment needed
- 10-29 mL/min: 500 mg every 24 hours
- <10 mL/min: 500 mg every 24 hours 1
Acyclovir adjustments:
25 mL/min: 800 mg every 4 hours, 5 times daily
- 10-25 mL/min: 800 mg every 8 hours
- <10 mL/min: 800 mg every 12 hours 1
Pain Management
Acute Pain
- Topical anesthetics for localized relief 1
- Oral analgesics following the WHO pain management ladder for moderate to severe pain 1
- Keep lesions clean and dry 1
Postherpetic Neuralgia Prevention
- Antiviral therapy alone does not significantly prevent postherpetic neuralgia (PHN) 5
- Early treatment with antivirals may reduce the severity and duration of acute pain 3, 4
Treatment Duration Considerations
- Standard treatment duration is 7 days 1, 2
- Extending treatment to 14 or 21 days has not shown significant additional benefits for preventing postherpetic neuralgia 6
Important Clinical Considerations
Efficacy Comparisons
- Valacyclovir has been shown to alleviate zoster-associated pain and postherpetic neuralgia faster than acyclovir in some studies 4
- Valacyclovir appears to have similar efficacy to famciclovir 500 mg three times daily 4
Common Adverse Effects
- Valacyclovir: Nausea and headache most commonly reported 4
- Acyclovir: Nausea, vomiting, diarrhea, and headache 4
Patient Education
- Apply medication at the first sign of prodrome
- Wash hands before and after application
- Continue treatment for the full prescribed duration even if symptoms improve 1
- Self-medication at the first sign of prodrome can reduce delay in treatment initiation 1
Monitoring
- Assess pain control throughout treatment
- Monitor for adverse effects of antiviral medications
- Follow up for development of postherpetic neuralgia, especially in older patients or those with severe acute pain
Remember that early treatment is crucial for maximizing effectiveness and potentially reducing the risk of complications like postherpetic neuralgia.