What is the recommended treatment for shingles?

Treatment of Shingles (Herpes Zoster)

The recommended first-line treatment for shingles is oral valacyclovir 1 gram three times daily for 7 days, initiated within 72 hours of rash onset to maximize effectiveness. 1

Antiviral Medication Options

• Valacyclovir 1 gram three times daily for 7 days is the FDA-approved dosage for herpes zoster treatment and should be initiated at the earliest sign or symptom of herpes zoster 1
• Acyclovir 800 mg orally five times daily for 7-10 days is an effective alternative treatment option, although the more frequent dosing may reduce compliance 2
• Famciclovir is also effective for herpes zoster treatment, though specific dosing for shingles is not mentioned in the provided evidence 3

Timing of Treatment

• Antiviral 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, 4
• Starting treatment later than 72 hours after rash onset may still provide benefit in reducing zoster-associated pain, though treatment should ideally begin as soon as possible 5

Special Populations

• For immunocompromised patients with severe disease or complications, intravenous acyclovir 5 mg/kg every 8 hours is recommended until clinical resolution is attained 6, 2
• Immunosuppressive therapy may need to be discontinued in severe cases of disseminated herpes zoster, though this decision should be made on a case-by-case basis 2

Pain Management

• Antiviral medications help reduce the duration of acute pain associated with herpes zoster 4, 5
• For postherpetic neuralgia (persistent pain after rash resolution):
  • Tricyclic antidepressants or anticonvulsants in low dosages may help control neuropathic pain 4
  • Narcotics may be required for adequate pain control in some cases 4
  • Capsaicin, lidocaine patches, and nerve blocks can be used in selected patients 4

Common Pitfalls to Avoid

• Using topical acyclovir is substantially less effective than oral therapy and is not recommended 2
• Inadequate dosing or duration of therapy may lead to treatment failure and increased risk of complications 2
• Failing to recognize and appropriately manage herpes zoster in immunocompromised patients, who require more aggressive therapy 2

Patient Education

• Patients should be advised that shingles lesions are contagious to individuals who have not had chickenpox and should avoid contact with susceptible individuals until lesions have crusted 6
• Patients should be informed that antiviral medications are most effective when started early in the course of the disease 1, 4
• Common side effects of antiviral medications include nausea, headache, and gastrointestinal disturbances 6, 5

Follow-up Recommendations

• Monitor for complete resolution of lesions; treatment may need to be extended if healing is incomplete after the initial course 2
• Extended follow-up may be needed for patients who develop postherpetic neuralgia 4