What is the recommended treatment for shingles?

Treatment of Shingles

The recommended first-line treatment for shingles (herpes zoster) is valacyclovir 1 gram three times daily for 7 days, initiated at the earliest sign or symptom of herpes zoster and ideally within 48 hours of rash onset. 1, 2

Antiviral Therapy Options

• First-line options:

  • Valacyclovir 1 gram three times daily for 7 days 1, 2
  • Famciclovir 500 mg three times daily for 7 days 1, 3

• Timing of treatment:

  • Initiate therapy at the earliest sign or symptom of herpes zoster 2, 3
  • Most effective when started within 48 hours of rash onset 2, 4
  • Can still be beneficial when started within 72 hours 4

Special Populations

Immunocompromised Patients

• May require longer duration of antiviral therapy 1
• Consider intravenous acyclovir for severe cases 1
• Monitor closely for disseminated disease 1

Pregnant Patients

• Acyclovir is preferred due to established safety profile 1

Pain Management

• Mild pain:

  • Acetaminophen or NSAIDs 1

• Moderate to severe pain:

  • Consider gabapentin, pregabalin, or tricyclic antidepressants 1
  • Lidocaine patches for localized pain 1
  • Follow WHO pain management ladder for escalation 1

Monitoring and Follow-up

• Schedule follow-up within 7 days to assess treatment response 1

• Monitor for:

  • Complete resolution of lesions
  • Signs of dissemination or complications
  • Need for ophthalmology evaluation if indicated

• Consider treatment failure if lesions do not begin to resolve within 7-10 days 1

Complications Management

Ocular Involvement

• Urgent ophthalmology referral for patients with:
  • Herpetic vesicles on the external auditory meatus 1
  • Risk of VZV conjunctivitis progressing to keratitis, corneal scarring, uveitis, and secondary glaucoma 1

Postherpetic Neuralgia Prevention

• Early antiviral therapy may help reduce the risk of postherpetic neuralgia 4
• Consider vaccination with herpes zoster vaccine for adults 50 years and older to prevent future outbreaks 1, 4

Common Pitfalls to Avoid

1. Delayed treatment: Initiating therapy beyond 72 hours significantly reduces efficacy 4

2. Inadequate pain management: Pain control is a critical component of shingles treatment 5

3. Missing ocular involvement: Failure to recognize and refer cases with potential eye involvement can lead to serious complications 1

4. Inappropriate dosing in renal impairment: Adjust acyclovir dosage based on creatinine clearance 1

5. Overlooking immunocompromised status: These patients require more aggressive management and closer monitoring 1