Treatment of Shingles (Herpes Zoster)
For patients with shingles, the recommended treatment is valacyclovir 1 gram three times daily for 7 days, initiated within 72 hours of rash onset to maximize effectiveness. 1
First-Line Antiviral Therapy Options
- Valacyclovir (preferred): 1 gram three times daily for 7 days 1
- Famciclovir: 500 mg three times daily for 7 days 2
- Acyclovir: 800 mg five times daily for 7 days 3
Valacyclovir is generally preferred due to its simpler dosing schedule and better bioavailability compared to acyclovir, which may improve adherence and outcomes 4. Studies have shown that valacyclovir accelerates the resolution of herpes zoster-associated pain compared to acyclovir 5, 4.
Timing of Treatment
Treatment should be initiated as soon as possible after diagnosis, ideally within 48 hours of rash onset 1. However, treatment may still be beneficial when started within 72 hours 6. Delayed treatment significantly reduces antiviral effectiveness.
Special Populations
Immunocompromised patients: May require longer treatment duration and closer monitoring 3
HIV-infected patients: May need extended therapy courses 3
Pregnant patients: Acyclovir can be safely used due to established safety profile 3
Renal impairment: Dose adjustment required based on creatinine clearance 3:
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
Pain Management
- Mild pain: Acetaminophen or NSAIDs 3
- Moderate to severe pain: Consider:
- Gabapentin (titrate to 2400 mg per day in divided doses)
- Pregabalin (particularly for post-herpetic neuralgia)
- Tricyclic antidepressants
- Serotonin-norepinephrine reuptake inhibitors 3
- Topical options: Capsaicin (8% dermal patch or cream) for peripheral neuropathic pain 3
Follow-up and Monitoring
- Re-examine patients 3-7 days after treatment initiation to assess response 3
- Evaluate for:
- Complete resolution of lesions
- Signs of dissemination or complications
- Treatment response
- Need for ophthalmology evaluation if ophthalmic involvement 3
Patient Education
- Advise patients to avoid close contact with susceptible individuals (especially pregnant women, immunocompromised individuals, and those without history of chickenpox) until lesions are crusted 3
- Explain that early treatment can reduce the risk of postherpetic neuralgia but may not eliminate it completely
- Recommend vaccination with herpes zoster vaccine for adults 50 years and older to prevent future outbreaks 3
Treatment Failure Considerations
If no improvement is seen after 3-7 days, consider:
- Incorrect diagnosis
- Co-infection with another pathogen
- Undiagnosed HIV infection
- Poor medication adherence
- Antiviral resistance 3
For severe cases requiring hospitalization, consider acyclovir 5-10 mg/kg IV every 8 hours until clinical improvement, then transition to oral therapy 3.