What is the treatment for shingles (herpes zoster) without a rash?

Treatment of Shingles Without a Rash

For shingles without a rash (zoster sine herpete), oral antiviral therapy with acyclovir, valacyclovir, or famciclovir should be initiated as soon as possible after diagnosis to reduce viral replication and prevent complications. 1

Diagnosis Considerations

• Zoster sine herpete (shingles without rash) is characterized by dermatomal pain in the absence of visible skin lesions, making diagnosis challenging 2
• Diagnosis is primarily clinical and may require a high index of suspicion, especially in elderly or immunocompromised patients 3
• Laboratory confirmation through PCR detection of VZV in affected nerves can be helpful when available 3

First-Line Treatment Options

• Oral antiviral medications are the mainstay of treatment and should be initiated as soon as possible 1, 4:

  • Acyclovir 800 mg orally 5 times daily for 7-10 days 4, 1
  • Valacyclovir 1000 mg orally 3 times daily for 7 days 4, 5
  • Famciclovir 500 mg orally 3 times daily for 7 days 4, 6

• Valacyclovir and famciclovir offer better bioavailability and less frequent dosing compared to acyclovir, potentially improving adherence 1, 7

Treatment Considerations for Special Populations

• For immunocompromised patients:

  • High-dose IV acyclovir remains the treatment of choice for severe VZV infections 4
  • Immunosuppressive therapy should be temporarily discontinued in severe cases of VZV infection 4
  • Treatment should continue for a minimum of 7-10 days 4

• For elderly patients:

  • Treatment is particularly important as they are at higher risk for complications including postherpetic neuralgia 8
  • Antiviral therapy should be initiated even in the absence of rash when zoster sine herpete is suspected 1, 2

Pain Management

• Pain control is a critical component of treatment 3:
  • Appropriately dosed analgesics in combination with a neuroactive agent (e.g., amitriptyline) are recommended 3
  • For neuropathic pain, consider tricyclic antidepressants or anticonvulsants such as gabapentin or pregabalin 9, 8

Monitoring and Follow-up

• Monitor for complete healing and resolution of pain 1
• Be aware that postherpetic neuralgia (pain persisting >90 days) is the most common complication, occurring in approximately 20% of patients 8
• Patients should be followed closely for development of any complications, especially those who are immunocompromised 4

Important Caveats

• Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 1
• Antiviral medications do not eradicate latent virus but help control symptoms and reduce complications 1
• The efficacy of antiviral therapy decreases when initiated more than 72 hours after symptom onset, but treatment may still provide benefit and should not be withheld based solely on duration of symptoms 7
• For immunocompromised patients with disseminated disease, intravenous acyclovir is recommended 4