What is the recommended treatment for shingles (Herpes Zoster) that returns after one week?

Treatment for Recurrent Shingles After One Week

For shingles (herpes zoster) that returns after one week, the recommended treatment is to restart antiviral therapy with valacyclovir 1 gram three times daily for 7 days. 1, 2

Antiviral Medication Options

First-line Treatment:

• Valacyclovir: 1 gram orally 3 times daily for 7 days 2
  • Most effective when started within 48 hours of rash onset
  • Better bioavailability than acyclovir
  • Simplified dosing regimen (3 times daily)

Alternative Options:

• Acyclovir: 800 mg orally 5 times daily for 7-10 days 1
  • Continue until all lesions have scabbed
• Famciclovir: 500 mg orally 3 times daily for 7 days 3

Treatment Duration

Treatment should continue until all lesions have scabbed, which typically requires 7-10 days of therapy 1. For recurrent cases, it's important to:

• Initiate therapy as soon as possible after symptoms appear
• Continue treatment for the full prescribed duration, even if symptoms begin to improve
• Monitor for complete resolution of lesions

Special Considerations for Recurrent Cases

When shingles returns after only one week, consider:

1. Possible immunocompromise: Recurrent or rapidly recurring shingles may indicate underlying immune dysfunction 4

   • Consider HIV testing or evaluation for other immunocompromising conditions
   • More frequent monitoring may be needed

2. Antiviral resistance: If the patient was previously on antiviral therapy, resistance should be considered 4

   • Switching to a different antiviral agent may be beneficial

3. Treatment duration: For recurrent cases, extending treatment beyond the standard 7 days may be necessary 1

   • Some patients may require up to 14 days of therapy, though studies show limited additional benefit 3

Dosage Adjustments

Adjust dosing based on renal function:

Creatinine Clearance (mL/min)	Valacyclovir Dosing
≥50 (normal)	No adjustment needed
30-49	No adjustment needed
10-29	1 gram every 24 hours
<10	500 mg every 24 hours

1, 2

Pain Management

Shingles-associated pain often requires additional management:

• Mild pain: Acetaminophen or NSAIDs
• Moderate pain: Consider adding gabapentin or pregabalin
• Severe pain: May require short-term opioid analgesics
• Topical options: Lidocaine patches or capsaicin cream for localized pain

Follow-up and Monitoring

• Schedule follow-up within 7 days to assess treatment response
• Monitor for complete resolution of lesions
• Evaluate for development of postherpetic neuralgia
• If symptoms worsen despite therapy, consider hospitalization and IV acyclovir, particularly for immunocompromised patients 4

Common Pitfalls to Avoid

1. Delayed treatment: Efficacy decreases when treatment is initiated >72 hours after rash onset, though some benefit may still be seen 3

2. Inadequate dosing: Underdosing antivirals can lead to treatment failure and increased risk of complications

3. Premature discontinuation: Stopping therapy before complete resolution can lead to recurrence or prolonged symptoms

4. Missing underlying causes: Failing to investigate reasons for recurrence (immunocompromise, malignancy, etc.)

5. Inadequate pain control: Pain management should be addressed concurrently with antiviral therapy

Recurrent shingles within such a short timeframe is unusual and warrants thorough evaluation for underlying conditions that may compromise immune function, while ensuring appropriate antiviral therapy is promptly initiated.