What is the recommended management for shingles?

Management of Shingles (Herpes Zoster)

The recommended first-line management for shingles is valacyclovir 1 gram three times daily for 7 days, initiated within 72 hours of rash onset to reduce acute pain and prevent postherpetic neuralgia. 1, 2

Antiviral Therapy

Antiviral medications are the cornerstone of shingles treatment:

• 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
  • Acyclovir: 800 mg five times daily for 7 days 4

• Timing is critical: Treatment should be initiated as soon as possible, ideally within 72 hours of rash onset 2, 5

• Special populations:

  • For immunocompromised patients: Consider longer duration of therapy and closer monitoring 1
  • For severe cases requiring hospitalization: Intravenous acyclovir 5-10 mg/kg every 8 hours 1

Pain Management

Pain control is essential and should be addressed simultaneously with antiviral therapy:

• Mild pain: Acetaminophen or NSAIDs 1

• Moderate to severe pain:

  • First-line: Gabapentin (titrate to 2400 mg per day in divided doses) 1
  • Alternatives: Pregabalin, tricyclic antidepressants (e.g., amitriptyline) 1, 6

• Localized pain:

  • Lidocaine patches 1
  • Capsaicin (8% dermal patch or cream) for peripheral neuropathic pain 1

Postherpetic Neuralgia Prevention and Management

Postherpetic neuralgia (PHN) is a common complication, especially in older adults:

• Prevention:

  • Early antiviral therapy is the best prevention strategy 5, 7
  • Valacyclovir has been shown to alleviate zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 7

• Treatment of established PHN:

  • Tricyclic antidepressants (amitriptyline or nortriptyline 10-25 mg initially, titrating up to 50-75 mg) 6
  • Gabapentin or pregabalin for neuropathic pain 1
  • For intractable cases: Consider referral to pain specialist 6

Important Clinical Considerations

• Renal adjustment: Dosage adjustment is necessary for patients with renal impairment 4

• Hydration: Maintain adequate hydration during treatment 4

• Monitoring: No laboratory monitoring is needed unless the patient has substantial renal impairment 1

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

• Transmission prevention: Advise patients to avoid contact with lesions to prevent transmission to susceptible individuals, particularly pregnant women, newborns, and immunocompromised persons 8

Follow-up

• Schedule follow-up within 7 days to assess treatment response 1
• Monitor for complete resolution of lesions and evaluate for signs of complications 1
• For persistent pain beyond 3 months (PHN), consider referral to a pain specialist 6

Pitfalls to Avoid

• Delayed treatment: Starting antiviral therapy beyond 72 hours significantly reduces efficacy, though some benefit may still be seen 7
• Inadequate pain control: Undertreatment of acute pain may increase risk of postherpetic neuralgia 6
• Missing ocular involvement: Always evaluate for ophthalmologic complications in facial/head zoster and refer to ophthalmologist if present 5
• Corticosteroid monotherapy: Corticosteroids alone without antivirals are not recommended and may increase viral shedding 9

Remember that shingles can be particularly severe in older adults and immunocompromised patients, requiring more aggressive management and closer monitoring for complications.