What is the recommended management for herpes zoster?

Management of Herpes Zoster

For herpes zoster (shingles), the recommended management includes prompt initiation of antiviral therapy with valacyclovir 1000 mg three times daily for 7 days or famciclovir 500 mg three times daily for 7 days, started within 72 hours of rash onset to reduce the duration and severity of acute disease and risk of postherpetic neuralgia. 1

Diagnosis

• Diagnosis is primarily clinical, based on:

  • Characteristic unilateral vesicular rash following a dermatomal distribution
  • Prodromal symptoms (burning, tingling, pain) occurring 24-72 hours before rash appearance
  • Direct lesion testing (when diagnosis is uncertain):
    • PCR testing of vesicle fluid (preferred)
    • Direct fluorescent antibody testing
    • Viral culture from blister material

• Note: Serology testing is not useful for diagnosing active herpes zoster 1

Antiviral Treatment

First-line Options:

• Valacyclovir: 1000 mg three times daily for 7 days 1
• Famciclovir: 500 mg three times daily for 7 days 1, 2

Alternative Option:

• Acyclovir: 800 mg five times daily for 7 days 3, 1
  • Less convenient dosing schedule
  • Lower bioavailability compared to valacyclovir and famciclovir 4

Treatment Considerations:

• Initiate treatment as soon as possible, ideally within 72 hours of rash onset 2, 5
• Continue treatment until all lesions have crusted over 1
• Complete the full 7-day course even if symptoms improve 1

Pain Management

Acute Pain:

• Mild pain: NSAIDs or acetaminophen 1
• Moderate to severe pain:
  • Gabapentin or pregabalin
  • Tricyclic antidepressants (nortriptyline, desipramine)
  • Opioids only as last resort for severe, refractory pain 1

Postherpetic Neuralgia (PHN):

• First-line options for persistent pain:
  • Gabapentin or pregabalin
  • Secondary amine TCAs (nortriptyline, desipramine)
  • SNRIs (duloxetine, venlafaxine)
  • Topical lidocaine patches 1

Special Populations

Immunocompromised Patients:

• Higher risk for severe disease, dissemination, and complications 1
• Treatment: Intravenous acyclovir initially, with transition to oral therapy once clinical improvement occurs 1
• May require longer treatment duration and closer monitoring 1

Ophthalmic Zoster:

• Requires immediate ophthalmology consultation 1
• Continue systemic antiviral therapy as above
• Topical antibiotics may be needed to prevent secondary bacterial infection 1
• Topical corticosteroids may be beneficial for inflammatory complications but should be used with caution and only in conjunction with systemic antiviral therapy 1

Prevention

• Zoster vaccination is recommended for adults aged 60 years and older to prevent future outbreaks and complications 1, 5
• Household contacts of immunocompromised persons should be vaccinated against VZV if they have no history of chickenpox and are seronegative for HIV 1

Monitoring and Follow-up

• Monitor for:
  • Resolution of skin lesions
  • Pain control
  • Development of complications (PHN, secondary bacterial infection, ocular involvement)
• Consider follow-up within 1-2 weeks of treatment initiation to assess response

Clinical Pearl

Valacyclovir and famciclovir are preferred over acyclovir due to more convenient dosing schedules and better pharmacokinetics, which may improve patient adherence and treatment outcomes 4. Early treatment (within 72 hours of rash onset) is crucial for reducing the severity and duration of acute herpes zoster and decreasing the risk of postherpetic neuralgia 6, 7.