What are the recommended medications for treating Herpes zoster?

Recommended Medications for Herpes Zoster (Shingles)

For uncomplicated herpes zoster, oral acyclovir or valacyclovir are the recommended first-line treatments, which should be continued until all lesions have scabbed. 1

Treatment Recommendations Based on Disease Severity

Uncomplicated Herpes Zoster

• Oral acyclovir 800 mg five times daily for 7-10 days 2
• OR valacyclovir 1000 mg three times daily for 7 days 3
• OR famciclovir 500 mg three times daily for 7 days 4
• Treatment should be continued until all lesions have scabbed 1
• Therapy should be initiated as soon as possible after diagnosis, ideally within 72 hours of rash onset 4, 3

Disseminated or Invasive Herpes Zoster

• Intravenous acyclovir is recommended 1
• A temporary reduction in immunosuppressive medication should be considered in immunocompromised patients 1
• Treatment should continue until all lesions have scabbed 1

Comparative Efficacy of Antiviral Medications

• Valacyclovir has better oral bioavailability than acyclovir and requires less frequent dosing (3 times daily vs 5 times daily) 3, 5
• Valacyclovir has been shown to alleviate zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 3
• Famciclovir is similarly effective to valacyclovir for speeding resolution of acute herpes zoster rash and shortening the duration of postherpetic neuralgia 3
• Famciclovir 500 mg three times daily for 7 days has been shown to accelerate lesion healing, reduce viral shedding, and significantly reduce the duration of postherpetic neuralgia compared to placebo 6

Special Considerations

Immunocompromised Patients

• Kidney transplant recipients with uncomplicated herpes zoster should receive oral acyclovir or valacyclovir 1
• For disseminated or invasive disease in immunocompromised patients, intravenous acyclovir with temporary reduction in immunosuppressive medication is recommended 1
• High-dose IV acyclovir remains the treatment of choice for VZV infections in severely compromised hosts 1

Timing of Treatment

• Antiviral therapy should ideally be initiated within 72 hours of rash onset 4, 3
• However, starting treatment later than 72 hours after rash onset may still provide benefit, particularly for reducing zoster-associated pain 3

Prevention After Exposure

For varicella-susceptible patients exposed to individuals with active varicella zoster infection:

• Varicella zoster immunoglobulin (or intravenous immunoglobulin) within 96 hours of exposure 1
• If immunoglobulin is not available or more than 96 hours have passed, a 7-day course of oral acyclovir beginning 7-10 days after varicella exposure 1

Common Pitfalls and Caveats

• Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 1
• Extending acyclovir treatment from 7 to 21 days provides only slight additional benefits and does not significantly reduce the frequency of postherpetic neuralgia 7
• Corticosteroids alone are not recommended for the treatment of herpes zoster and provide only slight benefits when added to antiviral therapy 7
• Antiviral medications do not eradicate latent virus but help control symptoms and reduce complications 1

Monitoring and Follow-up

• Monitor for complete healing of lesions 1
• Assess for development of postherpetic neuralgia, particularly in elderly patients 8
• In immunocompromised patients, monitor for signs of cutaneous and visceral dissemination; if present, switch to intravenous antiviral therapy 5