What is the recommended treatment for shingles?

Recommended Treatment for Shingles

The recommended first-line treatment for shingles (herpes zoster) is oral antiviral therapy with acyclovir 800 mg orally 5 times daily until clinical resolution, typically for 7-10 days, which should be started within 72 hours of rash onset for maximum effectiveness. 1

Antiviral Therapy 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
• Famciclovir: 500 mg orally 3 times daily for 7 days 2, 3

Valacyclovir and famciclovir have better bioavailability than acyclovir and require less frequent dosing, which may improve adherence. Studies show valacyclovir alleviates zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 2.

Key Treatment Principles:

• Start antiviral therapy as soon as possible, ideally within 72 hours of rash onset 1, 4
• Continue treatment until all lesions have scabbed or completely healed 1
• Extending treatment beyond 7 days (to 14 or 21 days) shows no significant advantage over the standard 7-day regimen 2, 5

Dose Adjustments for Special Populations

Renal Impairment

Dosage adjustment is required based on creatinine clearance 1:

Acyclovir dose adjustment:

• 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

Valacyclovir dose adjustment:

• CrCl ≥50 mL/min: No adjustment needed
• CrCl 30-49 mL/min: No adjustment needed
• CrCl 10-29 mL/min: 500 mg every 24 hours
• CrCl <10 mL/min: 500 mg every 24 hours

Immunocompromised Patients

• May require longer treatment duration and closer monitoring 1
• Consider hospitalization and IV acyclovir for worsening symptoms despite therapy 1

Children

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

Pain Management

Pain management is a critical component of shingles treatment:

1. Mild pain: Acetaminophen or NSAIDs 1
2. Moderate pain: Add gabapentin or pregabalin 1, 3
3. Severe pain: Consider short-term opioid analgesics 1

Topical options:

• Lidocaine patches (5%) 1, 3
• Capsaicin cream 1, 4

Postherpetic Neuralgia Prevention and Management

Postherpetic neuralgia (PHN) occurs in approximately 20% of patients with shingles, with higher risk in older patients 3, 6.

Risk factors for PHN:

• Advanced age 6
• Severity of acute pain 6
• Presence of viremia at presentation 6

PHN Treatment Options:

• Tricyclic antidepressants (e.g., amitriptyline, nortriptyline) 4, 3
• Anticonvulsants (gabapentin, pregabalin) 4, 3
• Topical lidocaine or capsaicin 3
• Nerve blocks for selected patients 4

Common Pitfalls and Caveats

1. Delayed treatment: Starting antivirals after 72 hours significantly reduces efficacy, though some benefit may still be seen 2, 6
2. Underdosing: Using inadequate doses can lead to treatment failure 1
3. Premature discontinuation: Stopping therapy before lesions have completely healed can lead to recurrence 1
4. Inadequate pain management: Pain control should be addressed concurrently with antiviral therapy 1
5. Missing underlying causes: Failure to identify immunocompromise or malignancy can worsen outcomes 1

Follow-up Recommendations

• Schedule follow-up within 7 days to assess treatment response 1
• Monitor for complete resolution of lesions 1
• Evaluate for development of postherpetic neuralgia 1

Wound Care

When practical, cleanse the affected area with mild soap and warm water, rinse thoroughly and gently pat dry 7.