What is the treatment for herpes zoster (shingles) rash?

From the Guidelines

Herpes zoster (shingles) rash treatment should begin with antiviral medications like acyclovir or famciclovir, administered within 72 hours of rash onset, as they have been shown to accelerate cutaneous healing and reduce the severity of acute pain in adults 1. When treating herpes zoster, it is essential to consider the timing of antiviral medication initiation, as it significantly impacts the effectiveness of the treatment.

• The recommended antiviral medications include acyclovir and famciclovir, which have been approved by the FDA for treating herpes zoster 1.
• These medications should be administered orally, with acyclovir typically given at a dose of 800 mg five times daily, and famciclovir at a dose of 500 mg three times daily, for a duration of 7-10 days.
• In addition to antiviral medications, pain management is crucial in treating herpes zoster, and can be achieved with over-the-counter options like acetaminophen or ibuprofen, progressing to prescription medications such as gabapentin or amitriptyline for more severe pain.
• Applying cool, wet compresses to the rash several times daily can help reduce inflammation and itching, while keeping the rash clean and avoiding scratching can prevent secondary infection.
• Topical treatments like calamine lotion or colloidal oatmeal baths can also help soothe the skin and reduce discomfort.
• It is also important to consider vaccination, such as the Shingrix vaccine, after recovery, especially for individuals over 50, to prevent future outbreaks.
• Patients should be advised to contact a healthcare provider immediately if they experience severe pain, rash near the eyes, widespread rash, or signs of infection like increased redness, swelling, or discharge.

From the FDA Drug Label

Herpes Zoster VALTREX is indicated for the treatment of herpes zoster (shingles) in immunocompetent adults. The efficacy of VALTREX when initiated more than 72 hours after the onset of rash and the efficacy and safety of VALTREX for treatment of disseminated herpes zoster have not been established.

The treatment for herpes zoster (shingles) rash is valacyclovir.

• The recommended dosage is 1 gram 3 times daily for 7 days.
• Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of the onset of rash 2.

Note: The efficacy of valacyclovir when initiated more than 72 hours after the onset of rash has not been established.

Alternatively, famciclovir can also be used to treat herpes zoster (shingles) 3.

From the Research

Treatment Options for Herpes Zoster (Shingles) Rash

• The treatment for herpes zoster (shingles) rash typically involves antiviral medications, such as acyclovir, famciclovir, and valacyclovir 4, 5, 6, 7.
• These medications are most effective when started within 72 hours after the onset of the rash 4, 7.
• The addition of an orally administered corticosteroid can provide modest benefits in reducing the pain of herpes zoster and the incidence of postherpetic neuralgia 4.
• Other treatment options for managing pain associated with herpes zoster include:
  • Tricyclic antidepressants or anticonvulsants, often given in low dosages, to control neuropathic pain 4.
  • Capsaicin, lidocaine patches, and nerve blocks can also be used in selected patients 4.
  • Narcotics for adequate pain control in patients with postherpetic neuralgia 4.

Special Considerations

• Immunocompromised patients require prompt antiviral therapy to reduce the incidence of cutaneous and visceral dissemination that can lead to life-threatening complications 8.
• For localized disease, most patients can be treated with oral valaciclovir, famciclovir, or aciclovir, with close outpatient follow-up 8.
• Intravenous aciclovir therapy is reserved for those with disseminated varicella zoster virus infection, ophthalmic involvement, very severe immunosuppression, or the inability to take oral medications 8.
• Foscarnet is the drug of choice to treat aciclovir-resistant herpes zoster 8.

Dosage and Administration

• Valacyclovir can be administered at a dose of 1.5 g twice daily for 7 days, which is as safe and effective as three times daily dosing for the reduction of zoster-associated pain and zoster-associated abnormal sensations 6.
• The dosing schedule of twice daily versus three times daily is desirable for enhancing patient compliance and to subsequently reduce the incidence of viral resistance 6.