What is the treatment for shingles?

Treatment for Shingles

The recommended treatment for shingles (herpes zoster) is valacyclovir 1000 mg three times daily for 7 days, famciclovir 500 mg three times daily for 7 days, or acyclovir 800 mg five times daily for 7 days, with treatment initiated as soon as possible after symptom onset. 1

First-Line Antiviral Therapy

Recommended Antiviral Options:

• Valacyclovir: 1000 mg orally three times daily for 7 days
• Famciclovir: 500 mg orally three times daily for 7 days
• Acyclovir: 800 mg orally five times daily for 7 days

Treatment should be initiated as soon as possible, ideally within 72 hours of rash onset, though it may still provide benefit if started later, especially in patients with new lesion formation, immunocompromised status, or severe pain 1.

Treatment Duration

• Standard treatment duration is 7 days
• Continue treatment until all lesions have crusted over
• Extending beyond 7 days has not shown significant additional benefits for most patients 1

Special Populations

Immunocompromised Patients

• Intravenous acyclovir is recommended initially
• Can transition to oral therapy once clinical improvement occurs
• May require longer treatment duration and closer monitoring 1

HIV-Infected Patients

• Famciclovir: 500 mg twice daily for 7 days 2
• Higher risk for atypical presentations, multidermatomal involvement, and disseminated disease 1

Pain Management

Acute Pain Control

1. Mild pain:

   • NSAIDs or acetaminophen

2. Moderate to severe pain:

   • Gabapentin
   • Pregabalin
   • Tricyclic antidepressants (nortriptyline, desipramine)

3. Severe refractory pain:

   • Short-term opioids may be considered as a last resort 1

Postherpetic Neuralgia Prevention

Early antiviral therapy may reduce the risk and duration of postherpetic neuralgia, which occurs in approximately 20% of patients 3. Famciclovir has been shown to reduce the duration of postherpetic neuralgia compared to placebo 4.

Ocular Involvement

If herpes zoster affects the ophthalmic branch of the trigeminal nerve:

• Urgent ophthalmology consultation
• Evaluation for conjunctivitis, keratitis, uveitis, and secondary glaucoma
• Systemic antivirals at standard doses
• Possible adjunctive topical antivirals 1

Treatment Efficacy Comparison

• Famciclovir has been shown to be superior to valacyclovir in relieving acute pain in some studies 5
• All three recommended antivirals (valacyclovir, famciclovir, acyclovir) have comparable efficacy for cutaneous healing 6
• The convenience of less frequent dosing with valacyclovir and famciclovir may improve adherence compared to acyclovir's five-times-daily regimen

Common Pitfalls to Avoid

1. Delayed treatment: Initiate antiviral therapy based on clinical suspicion without waiting for laboratory confirmation
2. Inadequate pain management: Address pain aggressively from the beginning
3. Missing ocular involvement: Always examine for eye involvement, especially with rash on the forehead or nose
4. Stopping treatment too early: Complete the full 7-day course even if symptoms improve
5. Overlooking immunocompromised status: These patients require more aggressive therapy and monitoring

Early treatment with antivirals is crucial for reducing the severity and duration of acute symptoms and may help prevent complications like postherpetic neuralgia.