What is the recommended treatment for shingles?

Shingles Treatment

For treatment of shingles (herpes zoster), oral antiviral therapy with acyclovir 800 mg 5 times daily for 7-10 days is the standard recommended treatment, which should be initiated at the earliest sign or symptom of herpes zoster. 1

First-Line Antiviral Options

Acyclovir

• Dosage: 800 mg 5 times daily for 7-10 days 1
• Continue until all lesions have scabbed (typically 7-10 days)
• Most effective when started within 72 hours of rash onset
• Common side effect: malaise (11.5%, comparable to placebo at 11.1%) 1

Alternative Antivirals

1. Valacyclovir

   • Dosage: 1 gram 3 times daily for 7 days 2
   • Better bioavailability than acyclovir
   • More convenient dosing schedule (3 times daily vs 5 times daily)
   • Should be initiated at earliest sign of herpes zoster 2

2. Famciclovir

   • Comparable efficacy to acyclovir 3
   • More convenient dosing schedule than acyclovir

Dosage Adjustments for Renal Impairment

Acyclovir Adjustment

Creatinine Clearance (mL/min)	Dose Adjustment for 800 mg
>25	800 mg every 4 hours, 5 times a day
10-25	800 mg every 8 hours
0-10	800 mg every 12 hours
[1]

Special Populations

Immunocompromised Patients

• May require longer treatment duration and closer monitoring 1
• Consider consultation with infectious disease specialist

Pregnant Patients

• Acyclovir can be safely used due to established safety profile 1

Herpes Zoster Ophthalmicus

• Requires prompt treatment
• Ophthalmology consultation recommended 1
• Same antiviral medications but with closer monitoring

Pain Management

Acute Pain

• Mild pain: Acetaminophen or NSAIDs
• Moderate to severe pain: Consider adding:
  • Gabapentin (titrate to 2400 mg per day in divided doses)
  • Pregabalin
  • Tricyclic antidepressants 1

Postherpetic Neuralgia

• First-line options:
  • Gabapentin
  • Pregabalin
  • Tricyclic antidepressants
• Topical options:
  • Capsaicin (8% dermal patch or cream) - can provide relief for up to 12 weeks
  • Lidocaine patches 1, 4

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 ocular involvement suspected

Treatment Failure

• If lesions don't begin to resolve within 7-10 days of starting therapy, suspect treatment failure
• Consider viral culture and susceptibility testing for suspected acyclovir-resistant HSV
• IV foscarnet is the treatment of choice for acyclovir-resistant cases 1

Prevention

• Vaccination with herpes zoster vaccine is recommended for adults 50 years and older 1, 4
• The CDC's Advisory Committee on Immunization Practices specifically recommends this vaccine for adults 60 years and older 4

Common Pitfalls to Avoid

1. Delayed treatment - Efficacy decreases when treatment is started >72 hours after rash onset
2. Inadequate pain management - Pain control should be addressed concurrently with antiviral therapy
3. Missing ocular involvement - Always check for eye involvement, especially with rash on forehead or nose
4. Insufficient treatment duration - Continue treatment until all lesions have crusted over
5. Overlooking renal function - Dose adjustment is critical in patients with renal impairment