What is the recommended treatment for herpes zoster?

Herpes Zoster Treatment

The recommended treatment for herpes zoster is oral antiviral therapy with valacyclovir 1000 mg three times daily, famciclovir 500 mg three times daily, or acyclovir 800 mg five times daily for 7 days, initiated within 72 hours of rash onset to reduce acute pain and prevent complications. 1

First-Line Antiviral Therapy

Recommended Antiviral Options:

• 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
• Brivudin: Once daily for 7 days (available in some countries) 2

Timing of Treatment:

• Initiate therapy as soon as possible after diagnosis
• Maximum benefit when started within 72 hours of rash onset
• Some benefit may still be achieved when started later, particularly in reducing pain 3

Special Populations

Immunocompromised Patients:

• May require intravenous acyclovir therapy (5-10 mg/kg every 8 hours) 1
• Longer treatment duration
• Closer monitoring for complications including disseminated disease
• Monitor for signs of cutaneous and visceral dissemination 4

Severe Disease Requiring Hospitalization:

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 5
• Consider for patients with disseminated infection, pneumonitis, hepatitis, or CNS complications

Patients with Renal Impairment:

• Dose adjustment required based on creatinine clearance
• Avoid nephrotoxic medications

Pain Management

Acute Pain:

• Gabapentin: First-line for severe shingles pain, titrated to 2400 mg per day in divided doses 1
• Start with 300 mg once daily and gradually increase
• Consider adding pregabalin for post-herpetic neuralgia

Post-Herpetic Neuralgia:

• Tricyclic antidepressants (nortriptyline or desipramine): Start at low doses and titrate up to 50-75 mg 1
• Capsaicin 8% patch: Single 30-minute application at the site of pain, providing relief for up to 12 weeks 1
• Pre-treatment with 4% lidocaine for 60 minutes can manage application-related discomfort

Adjunctive Therapies

Corticosteroids:

• May shorten the degree and duration of acute zoster pain
• No significant effect on preventing post-herpetic neuralgia 6
• Use with caution due to potential adverse events

Topical Treatments:

• Topical antivirals may be used as adjunctive treatment in unresponsive cases
• Not effective as monotherapy 1

Prevention

Vaccination:

• Recombinant zoster vaccine recommended for adults aged 50 years and older 1
• Most effective strategy to prevent herpes zoster and its complications

Clinical Pearls and Pitfalls

Common Pitfalls:

1. Delayed Treatment: Initiating antivirals beyond 72 hours significantly reduces efficacy
2. Inadequate Pain Management: Underestimating the severity of acute and chronic pain
3. Insufficient Monitoring: Failing to monitor immunocompromised patients for disseminated disease
4. Inappropriate Corticosteroid Use: Using corticosteroids without concurrent antiviral therapy

Important Considerations:

• Herpes zoster typically presents with unilateral vesicular eruption in a dermatomal distribution
• Prodromal pain often precedes the rash
• Lesions typically continue to erupt for 4-6 days in immunocompetent hosts
• Complete disease duration is approximately 2 weeks in healthy individuals 1

By following these evidence-based recommendations, clinicians can effectively manage herpes zoster, reduce acute symptoms, and minimize the risk of complications such as post-herpetic neuralgia.