Shingles Treatment
For shingles (herpes zoster), the recommended treatment is valacyclovir 1000 mg three times daily for 7 days, which should be initiated at the earliest sign or symptom of herpes zoster and within 48 hours of rash onset for maximum effectiveness. 1, 2
First-Line Antiviral Options
The American Academy of Dermatology recommends the following antiviral medications for shingles treatment:
- Valacyclovir: 1000 mg three times daily for 7 days (preferred due to convenient dosing)
- Acyclovir: 800 mg five times daily for 7 days
- Famciclovir: 500 mg three times daily for 7 days
These medications reduce the duration and severity of the disease when started promptly 1.
Timing of Treatment
- Optimal timing: Treatment should be initiated at the earliest sign or symptom of herpes zoster
- Maximum window: Most effective when started within 48 hours of rash onset
- Extended window: Recent observational data suggests benefit may still exist when treatment is started after 72 hours, though efficacy decreases 3
Special Populations
Renal Impairment
Dose adjustments are necessary based on creatinine clearance:
| Creatinine Clearance | Valacyclovir | Acyclovir |
|---|---|---|
| ≥50 mL/min (normal) | No adjustment | 800 mg every 4 hours, 5x daily |
| 30-49 mL/min | No adjustment | No adjustment |
| 10-29 mL/min | 500 mg every 24 hours | 800 mg every 8 hours |
| <10 mL/min | 500 mg every 24 hours | 800 mg every 12 hours |
Immunocompromised Patients
- Treatment should continue until complete healing of lesions
- HIV-infected patients may require higher oral doses
- Consult specialist for severe systemic infections 1
Pain Management
Postherpetic neuralgia (PHN) occurs in approximately 20% of patients with shingles, particularly in older adults 4. Management options include:
First-line options:
- Topical lidocaine patches
- Topical capsaicin
- Gabapentin or pregabalin
- Tricyclic antidepressants
For moderate to severe pain:
Duration of Treatment
Standard treatment duration is 7 days, with no significant benefit shown for longer treatments (14-21 days) 1, 5. A randomized trial comparing 7 days versus 21 days of acyclovir showed only slight benefits with the longer course and no reduction in postherpetic neuralgia 5.
Corticosteroids
The use of corticosteroids in addition to antiviral therapy remains controversial:
- May provide modest benefits in reducing acute pain
- May slightly accelerate rash healing
- Does not significantly reduce the incidence of postherpetic neuralgia
- Associated with more adverse events 5
Patient Education
Advise patients to:
- Initiate treatment at the earliest sign or symptom
- Take the full prescribed course even if symptoms improve
- Keep lesions clean and dry
- Seek medical attention for eye involvement (zoster ophthalmicus)
- Be aware that the medication reduces but does not eliminate the risk of postherpetic neuralgia 1, 6
Complications
Ocular involvement in herpes zoster can lead to serious complications and generally requires referral to an ophthalmologist 7.
Remember that while antiviral medications are effective at reducing the severity and duration of shingles, they do not completely eliminate the risk of postherpetic neuralgia, which remains the most common complication of herpes zoster.