What is the recommended treatment for shingles?

Shingles Treatment Recommendations

The standard recommended treatment for shingles (herpes zoster) in immunocompetent adults is oral acyclovir 800 mg administered 5 times daily for 7-10 days until all lesions have scabbed. 1

First-Line Antiviral Therapy Options

• Acyclovir: 800 mg orally 5 times daily for 7-10 days 1
• Valacyclovir: 1000 mg orally 3 times daily for 7 days 1, 2
• Famciclovir: 500 mg orally 3 times daily for 7 days 1, 3

Antiviral therapy should be initiated within 72 hours of rash onset for maximum effectiveness, though some benefit may still be achieved with later initiation 2.

Treatment Algorithm

1. Initiate antiviral therapy immediately upon diagnosis of shingles

   • Prioritize starting treatment within 72 hours of rash onset
   • Continue until all lesions have scabbed (typically 7-10 days)
   • Consider valacyclovir or famciclovir for improved compliance due to less frequent dosing 4, 2

2. Adjust dosing for renal impairment 1:

   • For creatinine clearance >25 mL/min: Standard dosing
   • For creatinine clearance 10-25 mL/min: Acyclovir 800 mg every 8 hours
   • For creatinine clearance <10 mL/min: Acyclovir 800 mg every 12 hours

3. Manage pain concurrently:

   • Mild pain: Acetaminophen or NSAIDs 1
   • Moderate to severe pain: Consider gabapentin (titrate to 2400 mg/day in divided doses), pregabalin, or tricyclic antidepressants 1
   • Topical options: Capsaicin 8% patch or cream, lidocaine patches 1, 3

4. Special considerations:

   • Immunocompromised patients: May require longer treatment duration and closer monitoring 1
   • Herpes zoster ophthalmicus: Requires prompt treatment and ophthalmology consultation 1
   • Pregnant patients: Acyclovir can be safely used 1

Prevention of Postherpetic Neuralgia

Postherpetic neuralgia (PHN) occurs in approximately 20% of patients with shingles 5. Early antiviral therapy helps reduce the risk and duration of PHN 2. Valacyclovir has been shown to alleviate zoster-associated pain and PHN significantly faster than acyclovir in clinical studies 2.

Follow-up Recommendations

Schedule follow-up within 7 days to 1:

• Assess treatment response
• Monitor for complete resolution of lesions
• Evaluate for complications
• Ensure ophthalmology evaluation has occurred if there is ocular involvement

Common Pitfalls to Avoid

• Delayed treatment: Initiating antiviral therapy beyond 72 hours reduces effectiveness, though some benefit may still be achieved 2
• Inadequate pain management: Pain control should be addressed concurrently with antiviral therapy 1, 3
• Missing ocular involvement: Always evaluate for herpes zoster ophthalmicus, which requires specialist consultation 1
• Failure to adjust dosing for renal impairment: Can lead to toxicity 1
• Not considering prevention: Recommend herpes zoster vaccination for adults 50 years and older 1, 5

If lesions don't begin to resolve within 7-10 days of starting therapy, consider treatment failure and evaluate for potential acyclovir-resistant HSV, which may require IV foscarnet 1.