What is the treatment for shingles (Herpes Zoster)?

Treatment of Shingles (Herpes Zoster)

For uncomplicated herpes zoster (shingles), oral antiviral therapy with acyclovir, valacyclovir, or famciclovir should be initiated within 72 hours of rash onset to reduce the duration of symptoms and risk of postherpetic neuralgia. 1, 2

First-Line Treatment Options

Antiviral Medications

• Valacyclovir: 1000 mg three times daily for 7 days 3
  • Alternative dosing: 1.5 g twice daily for 7 days (may improve compliance) 4
• Famciclovir: 500 mg three times daily for 7 days 5
• Acyclovir: 800 mg five times daily for 7 days 6

Valacyclovir and famciclovir are preferred over acyclovir due to:

• Better bioavailability
• Less frequent dosing (improving compliance)
• Greater effectiveness in shortening the duration of postherpetic neuralgia 7, 3

Treatment Algorithm Based on Severity

Uncomplicated Herpes Zoster

• Oral antiviral therapy (choose one):
  • Valacyclovir 1000 mg three times daily for 7 days
  • Famciclovir 500 mg three times daily for 7 days
  • Acyclovir 800 mg five times daily for 7 days
• Continue treatment until all lesions have scabbed 1
• Pain management with acetaminophen or NSAIDs for mild pain 2

Disseminated or Invasive Herpes Zoster

• Intravenous acyclovir (5-10 mg/kg every 8 hours for 5-7 days) 1, 2
• Temporary reduction in immunosuppressive medication if applicable 1
• Continue treatment until all lesions have scabbed 1

Special Populations

Immunocompromised Patients

• May require longer treatment duration and closer monitoring 2
• HIV-infected patients may need longer courses of therapy 2
• For suppressive therapy in HIV-infected patients: valacyclovir 500 mg twice daily 2

Renal Impairment

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 2

Management of Postherpetic Neuralgia

For moderate to severe pain that persists after rash resolution:

• First-line options:
  • Gabapentin (titrate to 2400 mg per day in divided doses) 2
  • Pregabalin (particularly effective for postherpetic neuralgia) 2
  • Tricyclic antidepressants 2
• Second-line options:
  • Capsaicin (8% dermal patch or cream) for peripheral neuropathic pain 2
  • Lidocaine patches 2
  • Opioid analgesics may be required for adequate pain control in severe cases 6

Follow-up and Monitoring

• Re-examine patients 3-7 days after initiation of therapy to assess treatment response 2
• Monitor for complete resolution of lesions 2
• Evaluate for signs of dissemination or complications 2
• For ocular involvement, refer to an ophthalmologist to prevent rare but serious complications 6

Prevention of Transmission

• Avoid direct contact with active lesions 2
• Avoid close contact with susceptible individuals (immunocompromised persons, pregnant women without history of chickenpox, newborns) until lesions have crusted 2

Common Pitfalls and Caveats

1. Delayed treatment: Antiviral therapy is most effective when started within 72 hours of rash onset, but may still provide benefit when started later 3
2. Inadequate pain management: Postherpetic neuralgia can be debilitating and may require multimodal therapy
3. Missing ocular involvement: Always assess for ocular involvement which requires ophthalmology referral 6
4. Undertreatment in immunocompromised patients: These patients may require more aggressive therapy and monitoring 2

Early initiation of antiviral therapy is crucial for reducing the duration of acute symptoms and decreasing the risk of postherpetic neuralgia, which is the most debilitating complication of herpes zoster, particularly in older adults 7, 5.