Treatment for Shingles Outbreak
The recommended first-line treatment for shingles (herpes zoster) is antiviral therapy with valacyclovir 1000 mg three times daily for 7 days, which should be started within 72 hours of rash onset for optimal effectiveness. 1
Antiviral Medication Options
- First-line options:
Valacyclovir and famciclovir are preferred over acyclovir due to their more convenient dosing schedules and better bioavailability 3, 4. Valacyclovir has been shown to alleviate zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 4.
Timing of Treatment
Starting antiviral therapy within 72 hours of rash onset provides the greatest benefit. However, treatment may still be beneficial when started later, especially in patients with:
- Ongoing new vesicle formation
- Immunocompromised status
- Severe pain
- Involvement of the face or eyes 5
Pain Management
Shingles often causes significant pain that requires management:
- Mild pain: Acetaminophen or NSAIDs 1
- Moderate to severe pain: Consider:
Special Considerations
Ocular Involvement
If herpes zoster affects the eye (ophthalmic zoster):
- Urgent ophthalmology referral is essential
- Risk of complications includes keratitis, corneal scarring, uveitis, and secondary glaucoma 1
- Continue antiviral therapy as above
Immunocompromised Patients
Patients with compromised immunity may require:
- Longer duration of antiviral therapy
- Closer monitoring for disseminated disease
- Consideration of intravenous acyclovir for severe cases 6
Pregnant Women
For pregnant patients with shingles:
- Acyclovir is the preferred treatment (800 mg orally 5 times daily)
- Continue until all lesions have scabbed or completely healed (typically 7-10 days)
- No pattern of adverse pregnancy outcomes has been reported with acyclovir use 1
Prevention of Complications
Postherpetic Neuralgia
This is the most common complication of shingles, occurring in approximately 20% of patients 5. Risk increases with age.
- Early antiviral therapy reduces the risk and duration of postherpetic neuralgia 4
- Consider adding oral corticosteroids in select patients without contraindications to provide modest benefits in reducing pain and incidence of postherpetic neuralgia 2
Follow-up
- Schedule follow-up within 7 days to assess treatment response
- Monitor for complete resolution of lesions
- Evaluate for signs of complications
- Ensure ophthalmology evaluation has occurred if there is facial or ocular involvement 1
Prevention
While there are no preventive measures available for an active shingles outbreak 6, vaccination with the herpes zoster vaccine is recommended for adults 50 years and older to prevent future outbreaks 5.