Treatment of Shingles
Oral antiviral therapy should be initiated within 72 hours of rash onset with valacyclovir 1 gram three times daily for 7 days, famciclovir 500 mg three times daily for 7 days, or acyclovir 800 mg five times daily for 7-10 days. 1, 2, 3
First-Line Treatment Options
- Valacyclovir 1 gram orally three times daily for 7 days is recommended for its convenient dosing schedule and excellent bioavailability 4, 2
- Famciclovir 500 mg orally three times daily for 7 days is equally effective with similar efficacy to valacyclovir 5, 2
- Acyclovir 800 mg orally five times daily for 7-10 days is effective but requires more frequent dosing which may reduce compliance 6, 1
Timing of Treatment
- Antiviral therapy should ideally be initiated within 72 hours of rash onset for maximum effectiveness 1, 3
- Some evidence suggests that starting treatment beyond 72 hours may still provide benefit, especially in reducing zoster-associated pain 2
- Treatment should be started as soon as possible after diagnosis to achieve the best outcomes 1, 3
Special Populations
Immunocompromised Patients
- Immunocompromised patients with shingles require more aggressive management 6
- For severe cases in immunocompromised patients, intravenous acyclovir 5 mg/kg every 8 hours may be necessary 6
- Immunosuppressive therapy should be discontinued in severe cases of varicella infection and disseminated herpes zoster 6
Complicated Shingles
- For complicated herpes zoster (multi-dermatomal, ophthalmic, visceral, or disseminated), intravenous acyclovir is recommended 6
- Ocular involvement in herpes zoster requires referral to an ophthalmologist to prevent rare but serious complications 1
Management of Pain
- Acute pain management may require analgesics including narcotics for adequate pain control 1
- For postherpetic neuralgia (pain persisting >90 days after rash onset):
Prevention of Complications
- The primary goal of antiviral therapy is to speed healing, reduce acute pain, and decrease the risk of postherpetic neuralgia 2, 7
- Both valacyclovir and famciclovir have been shown to reduce the duration of postherpetic neuralgia compared to placebo 2, 7
- Valacyclovir has demonstrated faster alleviation of zoster-associated pain compared to acyclovir in clinical trials 2
Common Pitfalls to Avoid
- Delaying treatment beyond 72 hours significantly reduces effectiveness of antivirals 1, 3
- Using topical acyclovir is substantially less effective than oral therapy and is not recommended 6
- Inadequate dosing or duration of therapy may lead to treatment failure and increased risk of complications 6, 1
- Failing to recognize and appropriately manage herpes zoster in immunocompromised patients, who may require more aggressive therapy 6
Follow-up Recommendations
- Monitor for complete resolution of lesions; treatment may need to be extended if healing is incomplete after the initial course 6
- Assess for development of postherpetic neuralgia, particularly in older patients who are at higher risk 1, 3
- Consider early pain management strategies to prevent development of chronic pain 1, 3