What is the recommended treatment for recurrent shingles (herpes zoster)?

Treatment for Recurrent Shingles (Herpes Zoster)

For recurrent herpes zoster (shingles), the recommended treatment is oral famciclovir 500 mg every 8 hours for 7 days, initiated as soon as shingles is diagnosed. 1

First-Line Antiviral Therapy Options

• Famciclovir 500 mg every 8 hours for 7 days is FDA-approved for herpes zoster treatment and should be initiated as soon as diagnosis is confirmed 1
• Valacyclovir 1000 mg three times daily for 7 days is an effective alternative with similar efficacy to famciclovir 2, 3
• Acyclovir 800 mg five times daily for 7 days can be used, though its lower bioavailability may limit efficacy compared to the prodrugs valacyclovir and famciclovir 2

Timing of Treatment

• Antiviral therapy is most effective when started within 72 hours of rash onset, but may still provide benefit when initiated later 2
• A large observational study showed that starting valacyclovir treatment later than 72 hours after rash onset still provided benefit in reducing zoster-associated pain 2
• Early treatment is crucial to limit viral replication, reduce acute symptoms, and potentially decrease the risk of postherpetic neuralgia 4

Dosing Adjustments for Special Populations

• For patients with renal impairment, dosage adjustments are necessary:
  • For creatinine clearance 40-59 mL/min: famciclovir 500 mg every 12 hours 1
  • For creatinine clearance 20-39 mL/min: famciclovir 500 mg every 24 hours 1
  • For creatinine clearance <20 mL/min: famciclovir 250 mg every 24 hours 1
• For immunocompromised patients, higher doses or longer treatment durations may be needed 5

Management of Pain and Complications

• For acute pain management during shingles episodes, analgesics should be used alongside antiviral therapy 3
• For postherpetic neuralgia (pain persisting >90 days after acute episode):
  • Tricyclic antidepressants or anticonvulsants (gabapentin, pregabalin) may help control neuropathic pain 6, 4
  • Topical treatments like lidocaine patches or capsaicin can provide localized relief 6, 4
  • Narcotics may be required for adequate pain control in severe cases 6

Prevention of Recurrences

• For patients with frequent recurrences, suppressive therapy may be considered:
  • Valacyclovir 1000 mg once daily is a recommended suppressive regimen 5
  • Acyclovir 400 mg twice daily is an alternative suppressive option 5
  • Famciclovir 250 mg twice daily can also be used for suppression 5
• Suppressive therapy can reduce recurrence frequency by ≥75% in patients with frequent episodes 5
• Safety has been documented for up to 6 years with acyclovir and 1 year with valacyclovir and famciclovir 5

Special Considerations

• Ocular involvement in herpes zoster requires prompt referral to an ophthalmologist to prevent serious complications 6
• 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 5
• Varicella zoster virus vaccination is recommended for adults 60 years and older to decrease the incidence of herpes zoster, including recurrences 4

Treatment Monitoring

• No laboratory monitoring is needed in patients receiving therapy unless they have substantial renal impairment 5
• After 1 year of continuous suppressive therapy, consider discontinuation to assess the patient's rate of recurrent episodes 5