What is the recommended treatment for shingles?

Shingles Treatment Recommendations

The standard recommended treatment for shingles (herpes zoster) 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 5 times daily for 7-10 days 1
• Valacyclovir: 1000 mg 3 times daily for 7 days 1, 2
• Famciclovir: 500 mg 3 times daily for 7 days 1, 2

Antiviral therapy is most effective when started within 72 hours of rash onset, though treatment may still be beneficial when initiated later 2. Valacyclovir and famciclovir have better bioavailability and more convenient dosing schedules than acyclovir, which may improve patient adherence 3, 2.

Dosage Adjustments for Renal Impairment

Acyclovir dosage should be adjusted based on creatinine clearance 1:

• CrCl >25 mL/min: 800 mg every 4 hours, 5 times daily
• CrCl 10-25 mL/min: 800 mg every 8 hours
• CrCl 0-10 mL/min: 800 mg every 12 hours

Pain Management

Acute pain management should follow a stepwise approach 1:

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

For postherpetic neuralgia (pain persisting >90 days after rash onset) 1, 4:

• Gabapentin or pregabalin as first-line therapy
• Tricyclic antidepressants
• Topical treatments: 8% capsaicin patch or lidocaine patches

Special Populations

Immunocompromised Patients

• May require longer treatment duration and closer monitoring 1
• Consider IV acyclovir for severe cases or disseminated disease

Herpes Zoster Ophthalmicus

• Requires prompt treatment and ophthalmology consultation 1
• Same antiviral regimens as standard herpes zoster

Pregnant Patients

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

Follow-up and Monitoring

• Schedule follow-up within 7 days to assess treatment response 1
• No laboratory monitoring required for immunocompetent patients with normal renal function 1
• Monitor for complete resolution of lesions and evaluate for complications

Common Pitfalls and Caveats

1. Delayed treatment: Initiating antiviral therapy beyond 72 hours significantly reduces efficacy, though treatment may still provide some benefit 2

2. Inadequate pain management: Pain control is essential to improve quality of life and prevent development of chronic pain syndromes 1, 4

3. Missing ocular involvement: Always carefully assess for eye involvement, which requires urgent ophthalmology referral 1

4. Extended antiviral treatment: Extending treatment beyond 7 days provides minimal additional benefit for most immunocompetent patients 1, 5

5. Corticosteroid use: Adding corticosteroids to antiviral therapy may provide modest short-term benefits for acute pain but does not prevent postherpetic neuralgia and may increase adverse events 5

6. Prevention: Consider recommending herpes zoster vaccination for adults 50 years and older to prevent future outbreaks 1, 4