What is the recommended treatment for shingles?

Recommended Treatment for Shingles (Herpes Zoster)

For shingles treatment, oral antiviral therapy should be initiated within 72 hours of rash onset, with valacyclovir 1 gram three times daily for 7 days being the preferred regimen to reduce duration of symptoms, accelerate lesion healing, and decrease the risk of postherpetic neuralgia. 1, 2

First-Line Antiviral Therapy

• Valacyclovir 1 gram orally three times daily for 7 days is recommended as first-line therapy for herpes zoster 1, 3
• Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48-72 hours of rash onset 1, 2
• Alternative antiviral options include:
  • Famciclovir 500 mg orally three times daily for 7 days 2
  • Acyclovir 800 mg orally five times daily for 7 days 2, 3

Treatment Considerations

• Valacyclovir has better oral bioavailability than acyclovir, requiring less frequent dosing (3 times daily vs 5 times daily), which may improve patient adherence 3
• Clinical studies have shown that valacyclovir alleviates zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 3
• Extending antiviral treatment beyond 7 days has not shown significant additional benefit 4
• Antiviral medications are generally well-tolerated with common side effects including nausea, headache, and gastrointestinal disturbances 5, 3

Special Populations

• For immunocompromised patients with severe disease or complications:
  • Intravenous acyclovir 5 mg/kg every 8 hours may be required 5
  • Longer duration of therapy may be needed until clinical resolution is attained 5
• For patients with ocular involvement (herpes zoster ophthalmicus):
  • Prompt referral to an ophthalmologist is recommended 2
  • Antiviral therapy should still be initiated immediately 2

Pain Management

• For acute pain associated with herpes zoster:

  • Analgesics should be prescribed based on pain severity 2
  • For mild pain: acetaminophen or NSAIDs 2
  • For moderate to severe pain: short-term opioid therapy may be necessary 2

• For postherpetic neuralgia (persistent pain after rash resolution):

  • Tricyclic antidepressants or anticonvulsants may help control neuropathic pain 2
  • Topical agents such as capsaicin or lidocaine patches can be used for localized pain 2

Important Clinical Considerations

• Early initiation of antiviral therapy is crucial - efficacy decreases significantly when started >72 hours after rash onset 1, 2
• High-quality evidence indicates that antiviral therapy alone does not significantly reduce the incidence of postherpetic neuralgia, though it may reduce the duration and severity of acute pain 6
• The addition of corticosteroids to antiviral therapy provides only modest benefits in reducing acute pain and does not significantly impact postherpetic neuralgia incidence 4
• Patients should be advised that lesions are contagious to individuals who have not had chickenpox and should avoid contact with susceptible individuals until lesions have crusted 5

Treatment Algorithm

1. Confirm diagnosis of herpes zoster based on clinical presentation (unilateral dermatomal rash with vesicles)
2. Initiate antiviral therapy immediately, ideally within 72 hours of rash onset
3. Select appropriate antiviral based on patient factors:
   • For most patients: Valacyclovir 1 gram three times daily for 7 days
   • If cost is a concern: Acyclovir 800 mg five times daily for 7 days
   • For severe cases or immunocompromised patients: Consider IV acyclovir
4. Provide appropriate pain management
5. Monitor for complications and consider referral if ocular involvement or severe disease