Recommended Treatment for Shingles
The recommended treatment for shingles (herpes zoster) is valacyclovir 1 gram three times daily for 7 days, initiated at the earliest sign or symptom of herpes zoster and ideally within 48 hours of rash onset. 1
First-Line Antiviral Medications
Antiviral therapy is 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 7-10 days 3
Valacyclovir and famciclovir are preferred over acyclovir due to their more convenient dosing schedule and improved bioavailability 4. Starting treatment within 72 hours of rash onset is ideal, but treatment may still be beneficial when started later 4.
Dosage Adjustments for Renal Impairment
For patients with renal impairment, dose adjustments are necessary:
| 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 |
Pain Management
Shingles often causes significant pain requiring a multi-modal approach:
- Mild pain: Acetaminophen or NSAIDs
- Moderate pain: Topical anesthetics (lidocaine 2%), keeping lesions clean and dry 3
- Severe pain: Systemic analgesics following the WHO pain ladder; may require opioids for adequate control 5
For postherpetic neuralgia (pain persisting >90 days after rash onset):
- First-line: Gabapentin or pregabalin
- Second-line: Tricyclic antidepressants (amitriptyline, nortriptyline)
- Topical options: Lidocaine patches or capsaicin cream 5
Special Populations
Immunocompromised Patients
- Higher doses or longer treatment duration may be required
- Consider IV acyclovir for severe cases (5-10 mg/kg every 8 hours) 3
Elderly Patients
- At higher risk for postherpetic neuralgia (15.9% at 6 months) 6
- Age and severity of initial pain are significant predictors of persistent pain 6
- More aggressive antiviral therapy should be considered
Prevention of Complications
Postherpetic neuralgia is the most common complication of shingles, occurring in approximately 20% of patients 5. Early antiviral therapy can reduce the risk and duration of postherpetic neuralgia 4.
For patients with ocular involvement (herpes zoster ophthalmicus), prompt referral to an ophthalmologist is essential to prevent vision-threatening complications 7.
Patient Education
- Patients should be advised to keep lesions clean and dry
- Avoid contact with immunocompromised individuals, pregnant women, and those without prior chickenpox infection
- Lesions are contagious until they crust over
- Inform patients that early treatment provides the best outcomes
The evidence clearly demonstrates that prompt antiviral therapy is the most effective approach for treating shingles and reducing the risk of postherpetic neuralgia, with valacyclovir offering advantages in terms of dosing convenience and bioavailability compared to acyclovir.