What is the recommended treatment for shingles?

Treatment for Shingles

For uncomplicated herpes zoster (shingles), oral antiviral therapy with valacyclovir 1000 mg three times daily for 7 days, famciclovir 500 mg three times daily for 7 days, or acyclovir 800 mg five times daily for 7 days should be initiated within 72 hours of rash onset to reduce symptom duration and risk of postherpetic neuralgia. 1

Antiviral Therapy

Antiviral medications are the cornerstone of shingles treatment and should be started as early as possible:

• First-line options (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 1, 2

• Treatment considerations:

  • Initiate therapy within 72 hours of rash onset for maximum effectiveness
  • Continue treatment until all lesions have scabbed 1
  • Valacyclovir and famciclovir have more convenient dosing schedules than acyclovir, potentially improving compliance 3

• Special populations:

  • Immunocompromised patients: May require longer treatment duration and closer monitoring 1
  • Severe cases: Consider IV acyclovir 5-10 mg/kg every 8 hours for 5-7 days 1
  • Renal impairment: Adjust dosing based on creatinine clearance 1

Pain Management

Pain control is essential and should be addressed alongside antiviral therapy:

• Mild pain:

  • Acetaminophen or NSAIDs 1, 4

• Moderate to severe pain:

  • First-line: Gabapentin (titrate to 2400 mg per day in divided doses) 1
  • Alternatives: Pregabalin, tricyclic antidepressants 1, 5

• Postherpetic neuralgia (pain persisting >90 days):

  • Topical options: Lidocaine patches, capsaicin (8% dermal patch or cream) 1, 5
  • Oral medications: Gabapentin, pregabalin, tricyclic antidepressants 1, 5
  • For severe cases: Consider referral for nerve blocks 4

Transmission Prevention

To prevent spreading the virus:

• Avoid direct contact with active lesions until they have crusted 1
• Practice good hygiene, including regular handwashing 1
• Avoid close contact with susceptible individuals (immunocompromised persons, pregnant women without history of chickenpox, and newborns) 1

Follow-up and Monitoring

• Re-examine patients 3-7 days after treatment initiation to:
  • Assess treatment response
  • Monitor for complete resolution of lesions
  • Evaluate for signs of dissemination or complications 1

Common Pitfalls and Caveats

• Delayed treatment: While antiviral therapy is most effective when started within 72 hours, some evidence suggests benefit may still exist with later initiation 6
• Insufficient pain management: Pain control should be addressed aggressively to prevent development of chronic postherpetic neuralgia
• Corticosteroids: Adding corticosteroids to antiviral therapy provides only minimal benefit in acute phase and does not reduce the frequency of postherpetic neuralgia 7
• Treatment duration: Extending antiviral treatment beyond 7 days has not shown significant additional benefit 7

Prevention

For prevention of future episodes, the herpes zoster vaccine is recommended for adults 50 years and older 1, 5.