Treatment for Shingles
For the treatment of herpes zoster (shingles), oral valacyclovir 1 gram three times daily for 7 days is the recommended first-line therapy. This treatment should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of rash onset 1.
Antiviral Medication Options
First-Line Options:
- 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 3
For Severe Cases or Immunocompromised Patients:
- Intravenous acyclovir: 5-10 mg/kg every 8 hours for 5-7 days until clinical resolution 3
- For acyclovir-resistant strains: Consider hospitalization and foscarnet 40 mg/kg IV every 8 hours until clinical resolution 3
Dosage Adjustments for Renal Impairment
For patients with renal impairment, adjust acyclovir dosage based on creatinine clearance:
| 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
Shingles often causes significant pain that may require specific management:
- Mild pain: Acetaminophen or NSAIDs 3
- Moderate to severe pain: Consider:
- Gabapentin (titrate to 2400 mg per day in divided doses)
- Pregabalin (particularly effective for post-herpetic neuralgia)
- Tricyclic antidepressants
- Serotonin-norepinephrine reuptake inhibitors 3
- Topical options: Capsaicin (8% dermal patch or cream) can provide relief for up to 12 weeks 3
Special Populations
- HIV-infected patients: May require longer courses of therapy and closer monitoring 3
- Pregnant patients: Acyclovir can be safely used due to its established safety profile 3
- Immunocompromised patients: Require longer treatment duration and closer monitoring 3
Patient Education and Prevention
- Advise patients to initiate treatment at the earliest sign or symptom of herpes zoster 2
- Patients should avoid close contact with others during active lesions to prevent transmission 3
- For adults 50 years and older, vaccination with the herpes zoster vaccine is recommended to prevent future outbreaks 3
Follow-up and Monitoring
- Re-examine patients 3-7 days after treatment initiation to assess response 3
- If no improvement is seen, consider:
- Incorrect diagnosis
- Co-infection
- HIV infection
- Poor medication adherence
- Antiviral resistance 3
Common Pitfalls to Avoid
- Delayed treatment: Antiviral therapy is most effective when started within 72 hours of rash onset, though some evidence suggests benefit even with later initiation 4
- Inadequate pain management: Post-herpetic neuralgia can be debilitating and requires aggressive treatment
- Missing ocular involvement: Ocular herpes zoster requires prompt ophthalmology evaluation to prevent complications
- Extending antiviral treatment unnecessarily: Studies show that extending acyclovir treatment to 21 days offers only slight benefits over the standard 7-day course 5