What is the recommended treatment for acute shingles?

Acute Treatment of Shingles

The recommended first-line treatment for acute shingles is oral acyclovir 800 mg five times daily for 7-10 days, which should be initiated within 72 hours of rash onset for maximum efficacy. 1

Antiviral Medication Options

First-line options:

• Acyclovir: 800 mg orally 5 times daily for 7-10 days 1
• Valacyclovir: 1000 mg orally 3 times daily for 7 days 2
  • Alternative dosing: 1.5 g twice daily (may improve compliance) 3
• Famciclovir: 500 mg orally 3 times daily for 7 days 2

Treatment timing:

• Initiate therapy as soon as possible, ideally within 48 hours of rash onset 1
• Treatment started within 72 hours significantly reduces:
  • Time to last new lesion formation
  • Loss of vesicles
  • Full crusting
  • Pain during treatment 1

Special Patient Populations

Renal Impairment

Dosage adjustment required based on creatinine clearance:

Acyclovir dosing:

• 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

Valacyclovir dosing:

• CrCl ≥30 mL/min: No adjustment needed
• CrCl 10-29 mL/min: 500 mg every 24 hours
• CrCl <10 mL/min: 500 mg every 24 hours 1

Immunocompromised Patients

• May require longer treatment duration
• Closer monitoring recommended
• Consider intravenous acyclovir
• Consider temporary reduction in immunosuppressive medication if applicable 1

Children

• For children <45 kg: Acyclovir 20 mg/kg body weight (maximum 800 mg/dose) orally 4 times daily for 7-10 days 1

HIV-infected Patients

• Higher oral doses may be required, especially with CD4+ counts <200 cells/µL 1

Treatment Duration

• Continue treatment until all lesions have scabbed, typically 7-10 days 1
• Extended treatment (21 days vs. 7 days) offers only slight additional benefits and is generally not recommended 4

Pain Management

For pain associated with shingles:

• Topical anesthetics (e.g., lidocaine 2%)
• Oral analgesics following WHO pain ladder
• Keep lesions clean and dry 1

Clinical Pearls and Pitfalls

Common Pitfalls:

1. Delayed treatment initiation: Starting treatment after 72 hours significantly reduces efficacy, though some benefit may still be observed 2
2. Inadequate dosing: Using lower doses (e.g., acyclovir 400 mg five times daily) has been shown to be less effective than the recommended 800 mg dose 5
3. Failure to adjust for renal function: Can lead to toxicity in patients with impaired renal function 1

Important Considerations:

• Corticosteroids (e.g., prednisolone) provide only modest additional benefit in acute phase and do not reduce postherpetic neuralgia risk 4
• Valacyclovir and famciclovir have better bioavailability than acyclovir, allowing for less frequent dosing and potentially better compliance 2
• Treatment should continue until all lesions have scabbed, even if this exceeds the standard 7-10 day period 1

Monitoring and Follow-up

• Monitor for resolution of cutaneous lesions
• Assess for adequate pain control
• Watch for development of complications (e.g., postherpetic neuralgia, ocular involvement)
• Ocular involvement merits referral to an ophthalmologist 6