Recommended Treatment for Shingles
The recommended treatment for shingles is valacyclovir 1000 mg three times daily for 7 days, or acyclovir 800 mg five times daily for 7 days, or famciclovir 500 mg three times daily for 7 days, with treatment initiated at the earliest sign or symptom of herpes zoster. 1
First-Line Antiviral Therapy
Antiviral therapy should be started as soon as possible, ideally within 72 hours of rash onset, to maximize effectiveness:
- Valacyclovir: 1000 mg orally three times daily for 7 days 1, 2
- Acyclovir: 800 mg orally five times daily for 7 days 1
- Famciclovir: 500 mg orally three times daily for 7 days 1, 3
Among these options, valacyclovir and famciclovir are preferred due to their more convenient dosing schedules compared to acyclovir's five-times-daily regimen 4.
Timing of Treatment
While antivirals are most effective when started within 72 hours of rash onset, treatment should not be withheld if this window has passed, especially in:
- Patients with ongoing new vesicle formation
- Immunocompromised patients
- Patients with severe pain or involvement of the eyes 1, 5
Special Populations
Immunocompromised Patients
- Treatment should continue until complete healing of lesions 1
- Higher doses may be necessary for HIV-infected patients 1
Renal Impairment
Dose adjustments are necessary based on creatinine clearance:
Valacyclovir adjustment:
- CrCl ≥50 mL/min: No adjustment needed
- CrCl 10-29 mL/min: 500 mg every 24 hours 1
Acyclovir adjustment:
- CrCl >25 mL/min: 800 mg every 4 hours, 5 times daily
- CrCl 10-25 mL/min: 800 mg every 8 hours
- CrCl <10 mL/min: 800 mg every 12 hours 1
Pain Management
Shingles-associated pain often requires a multi-modal approach:
Acute pain management:
- Topical anesthetics (e.g., lidocaine 2%)
- Oral analgesics following the WHO pain ladder
- Keeping lesions clean and dry 1
Prevention of postherpetic neuralgia (PHN):
- Early antiviral therapy reduces risk of PHN
- Consider adding systemic corticosteroids in selected patients without contraindications 5
Management of established PHN:
- First-line: Gabapentin, pregabalin, or tricyclic antidepressants
- Second-line: Topical lidocaine or capsaicin
- Severe cases: Referral to pain specialist 5
Ocular Involvement
If herpes zoster affects the ophthalmic branch of the trigeminal nerve:
- Immediate ophthalmology referral is recommended
- Continue antiviral therapy as above
- Specialist review is crucial to prevent long-term vision loss 1
Patient Education
Instruct patients to:
- Begin treatment at the earliest sign of shingles
- Complete the full 7-day course even if symptoms improve
- Keep lesions clean and dry
- Avoid contact with pregnant women who have never had chickenpox, newborns, and immunocompromised individuals until lesions have crusted 1, 3
Prevention
The zoster vaccine is recommended for adults ≥60 years to reduce the incidence of shingles and postherpetic neuralgia, but is not indicated for treating active shingles 6.