What is the recommended treatment for shingles?

Shingles Treatment

The recommended treatment for shingles (herpes zoster) is valacyclovir 1 gram three times daily for 7 days, which should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of rash onset. 1

First-Line Antiviral Therapy

Antiviral medications are the cornerstone of shingles treatment and should be started as soon as possible:

• Valacyclovir: 1 gram orally 3 times daily for 7 days 1
• Famciclovir: 500 mg orally 3 times daily for 7 days 2
• Acyclovir: 800 mg orally 5 times daily for 7 days 3

Valacyclovir is preferred over acyclovir due to:

• More convenient dosing (3 times daily vs 5 times daily) 4
• Better bioavailability 4
• More effective in shortening the duration of postherpetic neuralgia 4

Timing of Treatment

Early initiation of antiviral therapy is crucial:

• Ideally within 72 hours of rash onset 2
• Most effective when started within 48 hours of the onset of rash 1
• Some benefit may still be obtained when started later than 72 hours, particularly in patients with new vesicle formation or immunocompromised status 4

Pain Management

Pain control is an essential component of shingles treatment:

1. Acute pain management:

   • Acetaminophen or NSAIDs for mild pain
   • Opioid analgesics may be necessary for moderate to severe pain 3
   • Consider adding corticosteroids in selected patients without contraindications 5

2. For postherpetic neuralgia (pain persisting >90 days after rash onset):

   • Topical agents: lidocaine patches, capsaicin 2
   • Oral medications: gabapentin, pregabalin, tricyclic antidepressants 2

Special Populations

Immunocompromised Patients

• Higher doses and longer treatment durations may be necessary 6
• For HIV-infected patients with CD4+ count ≥100 cells/mm³, consider higher doses of oral antivirals 6

Ocular Involvement

• Herpes zoster ophthalmicus requires prompt referral to an ophthalmologist 3
• Antiviral therapy remains the cornerstone of treatment 3

Supportive Care

• Keep lesions clean and dry to promote healing 6
• Apply medication with clean hands or cotton swabs to avoid spreading the virus 6
• Topical anesthetics and sitz baths with warm water may provide symptomatic relief 6

Prevention

While not directly related to treatment, it's worth noting:

• Zoster vaccine is recommended for adults aged ≥60 years to prevent herpes zoster 7
• The vaccine is not indicated to treat acute zoster or prevent postherpetic neuralgia in those who already have shingles 7

Common Pitfalls to Avoid

1. Delayed treatment: Initiating antiviral therapy beyond 72 hours significantly reduces efficacy
2. Inadequate pain management: Pain control should be addressed aggressively from the start
3. Missing ocular involvement: Always assess for eye involvement, which requires specialist care
4. Inappropriate use of corticosteroids: These should not be used routinely in all patients but may benefit selected individuals when combined with antivirals 5