What is the recommended treatment for shingles?

Treatment of Herpes Zoster (Shingles)

The recommended first-line treatment for shingles is oral antiviral therapy with acyclovir 800 mg taken 5 times daily for 7-10 days, which should be initiated within 72 hours of rash onset for optimal effectiveness. 1

Antiviral Therapy Options

• First-line treatment:

  • Acyclovir: 800 mg orally 5 times daily for 7-10 days 1, 2
  • Alternative antivirals with better bioavailability:
    • Valacyclovir: 1000 mg orally 3 times daily for 7 days 3, 4
    • Famciclovir: 500 mg orally 3 times daily for 7 days 3, 4

• For severe cases or immunocompromised patients:

  • Intravenous acyclovir (10 mg/kg every 8 hours) for disseminated disease, encephalitis, pneumonitis, or hepatitis 1
  • Hospitalization may be required for severe cases 1

Dosage Adjustments for Special Populations

• Renal impairment: Adjust acyclovir dosage based on creatinine clearance 1:

  Creatinine Clearance	Dose Adjustment
  >25 mL/min	800 mg every 4 hours, 5 times daily
  10-25 mL/min	800 mg every 8 hours
  0-10 mL/min	800 mg every 12 hours

• Elderly patients: May require dose adjustment due to age-related changes in renal function 1

• Immunocompromised patients: May require longer treatment duration and closer monitoring 1

• 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

1. Acute pain management:

   • Mild pain: Acetaminophen or NSAIDs 1
   • Moderate to severe pain: May require stronger analgesics following the WHO pain management ladder 1
   • Topical options: Lidocaine patches for localized pain 1, 4

2. Postherpetic neuralgia (PHN) management:

   • Occurs in approximately 15-30% of patients at 3-6 months 4, 5
   • Treatment options:
     • Tricyclic antidepressants (often in low doses) 2, 4
     • Anticonvulsants: Gabapentin or pregabalin 1, 4
     • Topical agents: Capsaicin, lidocaine patches 2, 4
     • Nerve blocks for selected patients 2

Important Clinical Considerations

• Timing is critical: Antiviral therapy is most effective when started within 72 hours of rash onset 1, 2

  • However, treatment may still be beneficial when started later, especially in patients with ongoing new vesicle formation or high risk for complications 3

• Risk factors for PHN:

  • Advanced age (strongest predictor) 4, 5
  • Severity of acute pain 5
  • Presence of viremia at presentation 5

• Special situations requiring urgent attention:

  • Ophthalmic involvement: Requires urgent ophthalmologic consultation 1, 2
  • Disseminated disease: May require hospitalization and IV therapy 1

Prevention

• Zoster vaccine is recommended for adults 60 years and older to decrease the incidence of herpes zoster 4
• Patients with active lesions should avoid contact with susceptible individuals (pregnant women, immunocompromised individuals) 1

Common Pitfalls to Avoid

1. Delayed treatment: Many patients present after the 72-hour window, reducing treatment effectiveness. Educate patients about the importance of early presentation 5

2. Inadequate pain management: Pain control is essential both during acute infection and for prevention of PHN

3. Missing ophthalmic involvement: Always check for eye involvement, as this requires specialist care

4. Undertreatment in high-risk patients: Elderly and immunocompromised patients may need more aggressive therapy and closer monitoring 1