What is the recommended treatment for shingles?

Recommended Treatment for Shingles

The recommended treatment for shingles (herpes zoster) is oral valacyclovir 1 gram three times daily for 7 days, initiated at the earliest sign or symptom of herpes zoster and ideally within 48 hours of rash onset. 1

First-line Antiviral Therapy

• Valacyclovir 1 gram three times daily for 7 days is the FDA-approved regimen for herpes zoster treatment 1
• Therapy should be initiated at the earliest sign or symptom of herpes zoster for maximum effectiveness 1
• Treatment is most effective when started within 48 hours of the onset of rash 1, 2
• Alternative antiviral options include:
  • Famciclovir (dosing not specified in the provided evidence, but is an established alternative) 3, 2
  • Acyclovir (historically used at 800 mg five times daily for 7 days) 2, 4

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 for immunocompromised patients until clinical resolution is attained 5
• Starting treatment later than 72 hours after rash onset may still provide benefit, though treatment should ideally be given as soon as possible 6

Side Effects and Monitoring

• Antiviral medications are generally well-tolerated 5
• Common side effects include:
  • Nausea and headache (most common for both valacyclovir and famciclovir) 5, 6
  • Vomiting, diarrhea (for acyclovir) 6
  • Gastrointestinal disturbances 5

Patient Education

• Lesions are contagious to individuals who have not had chickenpox 5
• Patients should avoid contact with susceptible individuals until lesions have crusted 5
• Patients should be informed that antiviral treatment is not a cure for herpes zoster 3
• Patients should be advised to initiate treatment as soon as possible after diagnosis 3

Clinical Considerations

• Twice-daily dosing regimens (such as valacyclovir 1.5g twice daily) may help increase patient compliance compared to more frequent dosing schedules 7
• The addition of corticosteroids to antiviral therapy provides only slight benefits in acute herpes zoster and does not reduce the frequency of postherpetic neuralgia 4
• Antiviral therapy helps control acute symptoms but has limited effect on preventing postherpetic neuralgia according to some studies 8
• Ocular involvement in herpes zoster can lead to rare but serious complications and generally merits referral to an ophthalmologist 2

Management of Pain

• Burning pain typically precedes the rash by several days and can persist for several months after the rash resolves 2
• For postherpetic neuralgia (a complication of herpes zoster), additional pain management may be required:
  • Tricyclic antidepressants or anticonvulsants in low dosages may help control neuropathic pain 2
  • Narcotics may be required for adequate pain control in some patients 2
  • Capsaicin, lidocaine patches, and nerve blocks can be used in selected patients 2