What are the treatment guidelines for acute shingles?

Treatment Guidelines for Acute Shingles

For acute herpes zoster (shingles), acyclovir 800 mg orally 5 times daily for 7-10 days is the first-line treatment and should be initiated within 72 hours of rash onset for optimal effectiveness. 1

First-Line Antiviral Therapy Options

Recommended Regimens:

• Acyclovir: 800 mg orally 5 times daily for 7-10 days
• Valacyclovir: 1000 mg orally 3 times daily for 7 days
• Famciclovir: 500 mg orally 3 times daily for 7 days

Early initiation of antiviral therapy (within 72 hours of rash onset) is crucial for:

• Accelerating lesion healing
• Reducing viral shedding
• Decreasing acute pain severity
• Shortening the duration of postherpetic neuralgia 1, 2, 3

Dosage Adjustments for Renal Impairment

For acyclovir, adjust dosing based on creatinine clearance:

• CrCl >25 mL/min: 800 mg every 4 hours, 5 times daily
• CrCl 10-25 mL/min: 800 mg every 8 hours
• CrCl 0-10 mL/min: 800 mg every 12 hours 1

Pain Management

• Mild pain: Acetaminophen or NSAIDs
• Moderate to severe pain: Consider gabapentin, pregabalin, or tricyclic antidepressants
• Localized pain: Lidocaine patches may provide relief 1

Special Considerations

Immunocompromised Patients

• May require longer treatment duration and closer monitoring
• For severe cases: Intravenous acyclovir 10 mg/kg every 8 hours
• For acyclovir-resistant infections: Foscarnet 40 mg/kg IV 3 times daily 1

Pregnancy

• Acyclovir is the preferred treatment during pregnancy due to its established safety profile
• Continue treatment until all lesions have scabbed or completely healed 1

Ocular Involvement

• Urgent ophthalmology referral is essential for patients with herpetic vesicles on the external auditory meatus or any ocular symptoms
• Risk of complications includes conjunctivitis, keratitis, corneal scarring, uveitis, and secondary glaucoma
• Do not prescribe topical corticosteroids without concurrent antiviral therapy 1

Follow-up Recommendations

Schedule follow-up within 7 days to:

• Assess treatment response
• Monitor for complete resolution of lesions
• Evaluate for signs of dissemination or complications 1

Efficacy Comparison of Antiviral Agents

Research shows that valacyclovir and famciclovir offer similar efficacy to acyclovir but with more convenient dosing schedules:

• Valacyclovir (3 times daily) vs. acyclovir (5 times daily) 2
• Famciclovir has been shown to reduce the duration of postherpetic neuralgia compared to placebo 3

Prevention of Recurrence

Recurrence of shingles is unusual, and no drug has been proven to prevent recurrence 4. Therefore, long-term prophylaxis is not recommended after an episode of acute shingles.

Important Caveats

• Extending antiviral therapy beyond 7 days has not shown significant additional benefits 5
• The addition of corticosteroids to antiviral therapy may provide modest benefits in reducing acute pain but does not significantly reduce the incidence of postherpetic neuralgia and should be used with caution 5
• Topical antivirals alone are not effective for treating herpes zoster 1