Recommended Treatment for Shingles (Herpes Zoster)
For uncomplicated herpes zoster, 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 postherpetic neuralgia risk. 1
First-line Antiviral Therapy
Antiviral medications are the cornerstone of shingles treatment and should be started as soon as possible:
Preferred options (in order of convenience):
- 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
Treatment duration: Continue until all lesions have scabbed 1
Timing is critical: Antivirals are most effective when started within 72 hours of rash onset, though some evidence suggests benefit may still exist when started later 2
Dosage Adjustments for Renal Impairment
For patients with renal impairment, acyclovir dosage should be adjusted based on creatinine clearance:
| Creatinine Clearance (mL/min) | Dose Adjustment for 800 mg |
|---|---|
| >25 | 800 mg every 4 hours, 5 times daily |
| 10-25 | 800 mg every 8 hours |
| 0-10 | 800 mg every 12 hours |
Special Populations
Immunocompromised Patients
- May require longer treatment courses and closer monitoring 1
- Consider intravenous acyclovir (5-10 mg/kg every 8 hours for 5-7 days) for severe cases 1
HIV-Infected Patients
- May require longer courses of therapy
- For suppressive therapy: valacyclovir 500 mg twice daily 1
Pregnant Patients
- Acyclovir has an established safety profile in pregnancy 1
Pain Management
Shingles-associated pain requires a multi-tiered approach:
- Mild pain: Acetaminophen or NSAIDs 1
- Moderate to severe pain:
- Gabapentin (titrate to 2400 mg per day in divided doses)
- Pregabalin
- Tricyclic antidepressants 1
For Postherpetic Neuralgia
- First-line: Gabapentin, pregabalin, or tricyclic antidepressants
- Topical options: Capsaicin (8% dermal patch or cream) can provide relief for up to 12 weeks
- Lidocaine patches may be beneficial for localized pain 1, 3
Prevention of Transmission
- Avoid direct contact with active lesions
- Cover lesions until they have crusted
- Avoid close contact with immunocompromised persons, pregnant women without history of chickenpox, and newborns 1
Follow-up and Monitoring
- Re-examine patients 3-7 days after starting therapy to assess treatment response
- Monitor for complete resolution of lesions
- Evaluate for signs of dissemination or complications 1
Vaccination for Prevention
Common Pitfalls to Avoid
Delayed treatment: Starting antivirals after 72 hours significantly reduces efficacy, though treatment should still be initiated if the patient presents later 2
Inadequate pain management: Postherpetic neuralgia can be debilitating and requires aggressive management with appropriate medications 3
Missing ocular involvement: Herpes zoster ophthalmicus requires prompt ophthalmology referral to prevent serious complications 4
Prolonged antiviral therapy: Extended treatment (21 days vs. 7 days) offers minimal additional benefit 5
Relying solely on corticosteroids: While steroids may provide modest benefits for acute pain, they don't significantly reduce postherpetic neuralgia risk and should be used cautiously 5