Treatment of Herpes Zoster in a 69-Year-Old Female
For a 69-year-old female presenting with painful vesicular lesions on the right side of her back in the T10 dermatome consistent with herpes zoster (shingles), oral antiviral therapy with valacyclovir 1000 mg three times daily for 7 days is the indicated first-line treatment. 1
First-Line Antiviral Options
The CDC recommends the following oral antiviral medications for herpes zoster treatment:
- Valacyclovir: 1000 mg three times daily for 7 days 1
- Famciclovir: 500 mg three times daily for 7 days 1, 2
- Acyclovir: 800 mg orally 5 times daily for 7-10 days 1
Rationale for Valacyclovir as First Choice
- Better bioavailability compared to acyclovir (3-5 times higher) 3
- More convenient dosing schedule (three times daily vs. five times daily for acyclovir) 3
- Accelerates resolution of herpes zoster-associated pain 3
- Reduces duration of postherpetic neuralgia 3
Timing of Treatment
- Therapy should be initiated as soon as herpes zoster is diagnosed 2
- Treatment is most effective when started within 72 hours of rash onset 2, 4
- The efficacy of valacyclovir when initiated more than 72 hours after onset of rash has not been established 4
Treatment Algorithm
Confirm diagnosis: Unilateral vesicular lesions in a dermatomal distribution
Initiate antiviral therapy immediately with one of the following:
- Valacyclovir 1000 mg three times daily for 7 days (preferred)
- Famciclovir 500 mg three times daily for 7 days
- Acyclovir 800 mg five times daily for 7-10 days
For severe cases or immunocompromised patients: Consider intravenous acyclovir 10 mg/kg every 8 hours 1
Pain Management
- Mild pain: Acetaminophen or NSAIDs 1
- Moderate to severe pain: Consider gabapentin, pregabalin, or tricyclic antidepressants 1
- Localized pain: Lidocaine patches may provide relief 1
Special Considerations
Renal Impairment
Dose adjustment is necessary for patients with renal impairment:
- For famciclovir with creatinine clearance 20-39 mL/min: 500 mg every 24 hours 2
- For famciclovir with creatinine clearance <20 mL/min: 250 mg every 24 hours 2
Pregnancy
- Acyclovir is the preferred treatment during pregnancy due to its established safety profile 1
- Dosage: 800 mg orally 5 times daily 1
Follow-up
- Schedule follow-up within 7 days to assess treatment response 1
- Monitor for complete resolution of lesions 1
- Evaluate for signs of dissemination or complications 1
Potential Complications to Monitor
- Postherpetic neuralgia (more common in older patients)
- Secondary bacterial infection of lesions
- Ocular involvement if lesions are near the eye
Antiviral therapy has been shown to reduce acute pain duration, accelerate lesion healing, and may reduce the risk of postherpetic neuralgia, which is particularly important in this 69-year-old patient who is at higher risk for this complication 5, 3.