What is the recommended treatment for shingles?

Recommended Treatment for Shingles

For shingles (herpes zoster), the recommended treatment 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

Recommended Antiviral Options:

• Valacyclovir: 1 gram orally 3 times daily for 7 days 1
• Famciclovir: 500 mg orally 3 times daily for 7 days 2
• Acyclovir: 800 mg orally 5 times daily for 7 days 3

Key Treatment Principles:

• Initiate therapy as soon as possible, ideally within 48 hours of rash onset 1
• Treatment can still be beneficial when started up to 72 hours after rash onset 4
• Valacyclovir and famciclovir are preferred over acyclovir due to less frequent dosing and better bioavailability 4

Special Populations

Severe Cases Requiring Hospitalization:

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days until clinical resolution 3
• For acyclovir-resistant strains, consider foscarnet 40 mg/kg IV every 8 hours 3

Immunocompromised Patients:

• May require longer treatment duration and closer monitoring 3
• HIV-infected patients need longer courses of therapy 3

Renal Impairment:

Dose adjustments for acyclovir based on creatinine clearance:

• 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 3

Pain Management

Acute Pain:

• Mild pain: Acetaminophen or NSAIDs 3
• Moderate to severe pain: Consider gabapentin, pregabalin, or tricyclic antidepressants 3

Postherpetic Neuralgia:

• Gabapentin (titrate to 2400 mg per day in divided doses) as first-line treatment 3
• Alternatives: Tricyclic antidepressants, pregabalin, or serotonin-norepinephrine reuptake inhibitors 3
• Topical options: Lidocaine patches or capsaicin 8% dermal patch/cream 3, 5

Patient Education and Follow-up

Patient Instructions:

• Avoid close contact with others during active lesions to prevent transmission 3
• Abstain from sexual activity while lesions are present (for genital herpes) 3
• Re-examination 3-7 days after treatment initiation to assess response 3

Prevention:

• Herpes zoster vaccine is recommended for adults 50 years and older 3, 5

Common Pitfalls to Avoid

1. Delayed treatment: Initiating treatment beyond 72 hours after rash onset reduces efficacy, though some benefit may still be seen 4

2. Inadequate pain management: Postherpetic neuralgia occurs in approximately 20% of patients and requires aggressive management 5

3. Overlooking ocular involvement: Herpes zoster ophthalmicus requires prompt ophthalmology referral to prevent serious complications 6

4. Extended antiviral therapy: Extending acyclovir treatment from 7 to 21 days provides only slight additional benefits and is not routinely recommended 7

5. Relying solely on corticosteroids: Adding prednisolone to acyclovir therapy confers only slight benefits in acute phase and does not reduce the frequency of postherpetic neuralgia 7