What is the treatment for itching in a shingles episode?

Treatment of Itching in Shingles Episode

For itching associated with shingles, first-line treatment should include gabapentin for moderate to severe itching, along with topical therapies such as calamine lotion or colloidal oatmeal baths for symptomatic relief. 1

Pharmacological Management

Antiviral Therapy

• Initiate antiviral therapy within 72 hours of rash onset to reduce viral replication and associated symptoms including itching:
  • Valacyclovir 1000 mg three times daily for 7 days, OR
  • Famciclovir 500 mg every 8 hours for 7 days, OR
  • Acyclovir 800 mg five times daily for 7 days 1, 2

Medications for Itching

1. First-line for moderate to severe itching:

   • Gabapentin: Start at low dose and titrate up to 2400 mg daily in divided doses 1
   • Pregabalin: Alternative if gabapentin response is inadequate 1

2. For mild itching:

   • NSAIDs or acetaminophen 1
   • Antihistamines: Primarily for their sedative properties to help with sleep disturbance from itching 3
     • Note: Non-sedating antihistamines have little value for itch relief in shingles 3

3. For severe, refractory itching:

   • Tricyclic antidepressants (preferably nortriptyline or desipramine) starting with low doses and titrating up to 50-75 mg 1
   • Tramadol or short-term opioids may be considered as a last resort 1

Topical Treatments

• Calamine lotion for symptomatic relief
• Colloidal oatmeal baths to soothe itchy skin
• Capsaicin 8% patch: Can provide relief for up to 12 weeks with a single 30-minute application at the site of pain 1
• Cool compresses to reduce inflammation and itching
• Avoid soaps and detergents that can dry the skin and worsen itching 3

Non-Pharmacological Approaches

• Keep nails short to prevent skin damage from scratching 3
• Wear loose-fitting, cotton clothing to minimize irritation 3
• Avoid extreme temperatures that can worsen itching 3
• Consider alternative therapies:
  • Hypnosis: Recommended for neuropathic pain and itching 1
  • Cognitive behavioral therapy: Promotes patient acceptance and development of adaptive behaviors 1

Special Considerations

For Immunocompromised Patients

• May require more aggressive treatment:
  • Consider intravenous acyclovir 5-10 mg/kg body weight every 8 hours 3, 1
  • Continue treatment until clinical resolution is attained 3
  • Monitor closely for complications and secondary bacterial infection 1

For Ocular Involvement

• Immediate ophthalmology referral is required
• Topical antivirals may be used as adjunctive treatment 1
• Topical corticosteroids should be used with caution and under ophthalmologist supervision 1

Monitoring and Follow-up

• Monitor for signs of secondary bacterial infection (increased pain, swelling, purulent discharge)
• Assess response to therapy within 3-5 days
• If itching persists or worsens despite treatment, consider:
  1. Secondary bacterial infection
  2. Need for dose adjustment of medications
  3. Alternative diagnoses

Common Pitfalls to Avoid

1. Delaying antiviral therapy beyond 72 hours of rash onset significantly reduces effectiveness 2
2. Using non-sedating antihistamines, which have little value in shingles-related itching 3
3. Overuse of topical corticosteroids, which can delay healing and increase risk of secondary infection
4. Failing to recognize ocular involvement, which requires specialist care
5. Inadequate pain and itch control leading to sleep disturbance and decreased quality of life

By following this approach, most patients with shingles-related itching can achieve significant symptom relief while the underlying infection resolves.