What is the recommended treatment for recurrent shingles?

Treatment of Recurrent Shingles

For patients with recurrent shingles, antiviral therapy with valacyclovir 1 gram three times daily for 7 days is the recommended treatment, which should be initiated at the earliest sign or symptom of shingles to maximize effectiveness. 1

Antiviral Medication Options

First-Line Therapy

• Valacyclovir 1 gram orally 3 times daily for 7 days - therapy should be initiated at the earliest sign or symptom of herpes zoster 1
• Famciclovir 500 mg orally 3 times daily for 7 days 2
• Acyclovir 800 mg orally 5 times daily for 7 days 2

Key Considerations for Treatment

• Antiviral therapy is most effective when started within 72 hours after the onset of the rash 3
• Valacyclovir has better bioavailability than acyclovir, allowing for less frequent dosing and potentially better compliance 2
• Valacyclovir has been shown to alleviate zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 2

Suppressive Therapy for Frequent Recurrences

For patients with frequent recurrences (six or more per year), daily suppressive therapy should be considered:

• Daily suppressive therapy reduces the frequency of herpes recurrences by ≥75% 4

• Recommended suppressive regimens include:

  • Acyclovir 400 mg orally twice daily 4
  • Famciclovir 250 mg orally twice daily 4
  • Valacyclovir 500-1000 mg orally once daily (1000 mg preferred for patients with ≥10 episodes per year) 4
  • Valacyclovir 250 mg orally twice daily 4

• Safety and efficacy have been documented for daily therapy with acyclovir for up to 6 years, and with valacyclovir and famciclovir for 1 year 4

Management of Pain

• Early antiviral therapy helps reduce acute pain and may decrease the risk of postherpetic neuralgia 2
• For postherpetic neuralgia:
  • Tricyclic antidepressants or anticonvulsants in low dosages may help control neuropathic pain 5
  • Narcotics may be required for adequate pain control in severe cases 5
  • Topical treatments such as capsaicin or lidocaine patches can be used in selected patients 5

Special Considerations

Immunocompromised Patients

• Immunocompromised patients may require higher doses or longer treatment courses 4
• For patients with HIV, valacyclovir suppressive therapy should be 500 mg twice daily rather than once daily 4
• In cases of suspected resistance to standard antivirals (rare in immunocompetent patients but more common in immunocompromised hosts):
  • Consider foscarnet 40 mg/kg three times daily or 60 mg/kg twice daily for 10 days 6

Monitoring and Follow-up

• No laboratory monitoring is needed in patients receiving suppressive therapy unless they have substantial renal impairment 4
• After 1 year of continuous suppressive therapy, consider discontinuation to assess the patient's rate of recurrent episodes, as recurrence frequency often decreases over time 4

Common Pitfalls and Caveats

• Delaying treatment beyond 72 hours after rash onset may reduce the effectiveness of antiviral therapy, though some benefit may still be seen 2
• Extending acyclovir treatment from 7 to 21 days has shown only slight additional benefits and does not significantly reduce the frequency of postherpetic neuralgia 7
• Suppressive treatment reduces but does not eliminate asymptomatic viral shedding 4
• Resistance to antiviral medications is rare in immunocompetent patients but should be suspected if lesions do not begin to resolve within 7-10 days of therapy 4