Treatment of Shingles (Herpes Zoster)
The recommended treatment for patients presenting with shingles is valacyclovir 1 gram three times daily for 7 days, initiated at the earliest sign or symptom of herpes zoster. 1
First-Line Antiviral Therapy
Antiviral therapy should be started as soon as possible, ideally within 72 hours of rash onset:
- Valacyclovir: 1 gram 3 times daily for 7 days 1
- Famciclovir: 500 mg 3 times daily for 7 days 2
- Acyclovir: 800 mg 5 times daily for 7 days
Valacyclovir is often preferred over acyclovir due to:
- Less frequent dosing (3 times daily vs 5 times daily)
- Better bioavailability (3-5 times higher than acyclovir) 3
- Significantly faster resolution of zoster-associated pain compared to acyclovir 3
- Similar safety profile to acyclovir 3
Timing of Treatment
Treatment efficacy is highest when initiated within 72 hours of rash onset 1. However, antiviral therapy should still be considered even after this window, particularly in:
- Patients with continued new vesicle formation
- Immunocompromised patients
- Patients with severe pain
- Patients with involvement of the face or eyes
Special Populations
Renal Impairment
Dosage adjustment is necessary for patients with renal impairment 1:
| Creatinine Clearance (mL/min) | Valacyclovir Dose Adjustment |
|---|---|
| >50 | No adjustment needed |
| 30-49 | 1 gram twice daily |
| 10-29 | 1 gram once daily |
| <10 | 500 mg once daily |
Immunocompromised Patients
- May require longer treatment duration
- Consider higher doses or intravenous therapy in severe cases
- Closer monitoring for complications
Ophthalmic Involvement
- Urgent ophthalmology consultation is required
- Consider higher doses or longer duration of therapy
Pain Management
Pain management is a critical component of shingles treatment:
Acute pain:
- Acetaminophen or NSAIDs for mild pain
- For moderate to severe pain, consider:
- Gabapentin (titrate to 2400 mg per day in divided doses)
- Tricyclic antidepressants
- Opioid analgesics for severe pain
Prevention of postherpetic neuralgia:
Monitoring and Follow-up
- Re-examine patients within 3-7 days after initiation of therapy to assess treatment response
- If no improvement is seen, consider:
- Incorrect diagnosis
- Antiviral resistance
- Poor medication adherence
- Immunocompromised status
Complications to Watch For
- Postherpetic neuralgia (pain persisting >90 days after rash onset)
- Secondary bacterial infection of skin lesions
- Ocular complications (if ophthalmic division of trigeminal nerve involved)
- Neurological complications (motor neuropathy, encephalitis)
Prevention
For prevention of future episodes, herpes zoster vaccination is recommended for adults 50 years and older.