Shingles Treatment
The recommended first-line treatment for shingles (herpes zoster) is valacyclovir 1 gram three times daily for 7 days, initiated within 48 hours of rash onset for optimal effectiveness. 1, 2
Antiviral Therapy Options
First-Line Treatment:
- Valacyclovir: 1 gram orally three times daily for 7 days 1, 2
- Most effective when started within 48 hours of rash onset
- Continue treatment until all lesions have completely crusted over 1
- May need to extend beyond 7 days if lesions are not fully crusted
Alternative Options:
- Famciclovir: 500 mg orally three times daily for 7 days 3, 4
- Acyclovir: 800 mg orally five times daily for 7-10 days 1, 5
- Less convenient dosing schedule compared to valacyclovir
- Lower bioavailability than valacyclovir 4
Dosage Adjustments for Renal Impairment
| Creatinine Clearance (mL/min) | Valacyclovir Dosing |
|---|---|
| ≥50 (normal) | No adjustment needed |
| 30-49 | No adjustment needed |
| 10-29 | 500 mg every 24 hours |
| <10 | 500 mg every 24 hours |
Special Patient Populations
Immunocompromised Patients:
- Higher doses and longer treatment durations may be necessary 1
- For HIV-infected patients with CD4+ count ≥100 cells/mm³, higher doses of oral antivirals are recommended 1
- Close monitoring for adverse effects is essential
Elderly Patients:
- Standard dosing is appropriate, but monitor renal function
- Elderly patients are at higher risk for postherpetic neuralgia 6
Pain Management
Acute pain management during shingles:
- Topical anesthetics (e.g., lidocaine 2%) 1
- Oral analgesics following the WHO pain ladder for moderate to severe pain 1
- Keeping lesions clean and dry 1
Complications and Follow-up
Postherpetic Neuralgia (PHN):
- Most common complication, occurring in approximately 20% of patients 6
- Risk factors: advanced age, severe acute pain, severe rash, prodromal pain
- Treatment options for established PHN:
Ocular Involvement:
- Occurs in 10-25% of zoster episodes 7
- Refer to ophthalmologist if herpes zoster ophthalmicus is suspected 5
Patient Education and Isolation
- Patients remain infectious until all lesions are completely crusted over 1
- Avoid contact with immunocompromised individuals, pregnant women, and those without history of chickenpox
- Initiate treatment at earliest sign of shingles 1, 2
Prevention
- Zoster vaccine is recommended for adults ≥60 years (per CDC ACIP) 7
- Vaccine reduces the incidence of herpes zoster and postherpetic neuralgia 7
- Not indicated for treatment of acute zoster or established PHN 7
Important Clinical Pearls
- Early treatment (within 72 hours of rash onset) is crucial for maximizing effectiveness 1, 2, 4
- Treatment should continue until all lesions are completely crusted over, even if this requires extending beyond the standard 7-day course 1
- Adding corticosteroids to antiviral therapy provides only modest benefits in reducing acute pain and does not significantly reduce the risk of postherpetic neuralgia 8
- Valacyclovir has been shown to alleviate zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 4