Treatment of Shingles (Herpes Zoster)
The most effective treatment for shingles is antiviral therapy with valacyclovir 1000 mg three times daily, famciclovir 500 mg three times daily, or acyclovir 800 mg five times daily for 7 days, initiated within 72 hours of rash onset, combined with appropriate pain management. 1
Clinical Presentation and Diagnosis
Herpes zoster (shingles) is caused by reactivation of the varicella zoster virus (VZV), which remains dormant in the dorsal root ganglia after a primary varicella infection (chickenpox). The clinical presentation typically includes:
- Prodromal symptoms: Pain, burning, tingling, or itching in the affected dermatome 2-3 days before rash appears
- Characteristic rash: Unilateral, dermatomal distribution of painful vesicular lesions
- Progression: Vesicles that evolve through stages of pustulation and crusting over 7-10 days
The diagnosis is typically made clinically based on the characteristic presentation. When diagnosis is uncertain, direct testing of lesion material via PCR testing of vesicle fluid is preferred over serology 1.
Antiviral Therapy
Early antiviral therapy is crucial and should be initiated within 72 hours of rash onset. Options include:
- Valacyclovir: 1000 mg three times daily for 7 days 2
- Famciclovir: 500 mg three times daily for 7 days 3
- Acyclovir: 800 mg five times daily for 7 days 4
Valacyclovir and famciclovir are preferred over acyclovir due to better bioavailability and less frequent dosing requirements 1. Treatment should continue until all lesions have crusted over, typically 7 days 1.
For immunocompromised patients, intravenous acyclovir may be required initially, with transition to oral therapy once clinical improvement occurs 1.
Pain Management
Pain control is an essential component of shingles treatment:
- Mild pain: NSAIDs or acetaminophen
- Moderate to severe pain: Gabapentin (first-line) titrated from low dose to up to 2400 mg daily in divided doses
- Inadequate response to gabapentin: Consider pregabalin or tricyclic antidepressants (nortriptyline or desipramine starting at low doses and titrating up to 50-75 mg)
- Severe refractory pain: Short-term opioids may be considered as a last resort 1
Postherpetic Neuralgia (PHN)
Postherpetic neuralgia is the most common complication of shingles, occurring in approximately 20% of patients 5. It is defined as pain persisting more than 90 days after the rash has healed 5. Treatment options include:
- Topical agents: Lidocaine patches or capsaicin 8% patch
- Oral medications: Gabapentin, pregabalin, or tricyclic antidepressants
- Alternative therapies: Cognitive behavioral therapy, physical therapy, or hypnosis 1
Special Considerations
Ocular Involvement
When herpes zoster affects the ophthalmic division of the trigeminal nerve, prompt evaluation for:
- Conjunctivitis, keratitis, uveitis/iritis
- Secondary glaucoma
- Corneal scarring
Ophthalmology consultation is recommended for patients with ocular involvement 1.
Immunocompromised Patients
Patients with HIV, cancer, or on immunosuppressive medications are at higher risk for:
- Atypical presentations
- Multidermatomal involvement
- Disseminated disease
- Higher complication rates
These patients may require more aggressive therapy and closer monitoring 1.
Prevention
- Zoster vaccination is recommended for adults aged 60 years and older to prevent future outbreaks and complications 1
- Household contacts of immunocompromised persons should be vaccinated against VZV if they have no history of chickenpox 1
Common Pitfalls to Avoid
- Delayed treatment: Initiating antiviral therapy beyond 72 hours significantly reduces efficacy
- Inadequate pain management: Underestimating the severity of acute pain can lead to increased risk of postherpetic neuralgia
- Missing ocular involvement: Failing to recognize and promptly refer patients with ophthalmic zoster can lead to vision-threatening complications
- Inappropriate use of corticosteroids: Topical corticosteroids should be used with caution, especially in ocular involvement
By following these evidence-based guidelines, clinicians can effectively manage shingles and reduce the risk of complications, particularly postherpetic neuralgia, which can significantly impact quality of life.