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, 2

First-Line Antiviral Therapy

Three antiviral medications are recommended for treating shingles:

• Valacyclovir: 1 gram three times daily for 7 days 1, 2
• Famciclovir: 500 mg three times daily for 7 days 1, 3
• Acyclovir: 800 mg five times daily for 7-10 days 1

Antiviral therapy should be initiated as soon as possible, ideally within 72 hours of rash onset for maximum effectiveness 2, 4. However, treatment may still be beneficial when started later than 72 hours after rash onset, particularly in patients with ongoing new vesicle formation or in immunocompromised patients 5.

Dosage Adjustments for Renal Impairment

For patients with renal impairment, dosage adjustments are necessary:

Acyclovir dosage adjustments based on creatinine clearance:

• >25 mL/min: 800 mg every 4 hours, 5 times daily
• 10-25 mL/min: 800 mg every 8 hours
• 0-10 mL/min: 800 mg every 12 hours 1

Pain Management

Shingles often causes significant pain requiring multimodal management:

• Mild pain: Acetaminophen or NSAIDs 1
• Moderate to severe pain: Consider:
  • Gabapentin (titrate to 2400 mg per day in divided doses) 1
  • Pregabalin (particularly for post-herpetic neuralgia) 1
  • Tricyclic antidepressants 1, 4
  • Serotonin-norepinephrine reuptake inhibitors 1

For topical relief:

• Capsaicin (8% dermal patch or cream) can provide relief for up to 12 weeks 1
• Lidocaine patches 4

Special Populations

Immunocompromised Patients

• May require longer treatment duration and closer monitoring 1
• HIV-infected patients may need longer courses of therapy 1
• For severe manifestations, consider IV acyclovir 5-10 mg/kg every 8 hours until clinical resolution 1

Pregnant Patients

• Acyclovir has an established safety profile in pregnancy 1

Ocular Involvement

• Patients with herpes zoster ophthalmicus should be referred to an ophthalmologist due to risk of serious complications 6, 4

Follow-up and Prevention

• Re-examine patients 3-7 days after initiation of therapy to assess treatment response 1

• Schedule follow-up within 7 days to:

  • Monitor for complete resolution of lesions
  • Evaluate for signs of dissemination or complications 1

• Vaccination with herpes zoster vaccine is recommended for adults 50 years and older to prevent future outbreaks 1, 4

Treatment Failure

If no improvement is seen, consider:

• Incorrect diagnosis
• Co-infection
• Poor medication adherence
• Development of antiviral resistance 1

For acyclovir-resistant strains in severe cases, foscarnet 40 mg/kg IV every 8 hours until clinical resolution may be considered 1.