What is the recommended treatment for shingles?

Treatment of Shingles (Herpes Zoster)

The recommended first-line treatment for shingles is oral antiviral therapy with valacyclovir 1 gram three times daily for 7 days, initiated within 72 hours of rash onset to reduce acute pain and prevent complications. 1, 2

First-Line Antiviral Options

• Valacyclovir 1 gram three times daily for 7 days is the recommended first-line treatment due to its convenient dosing schedule and proven efficacy 1
• Alternative antiviral options include:
  • Acyclovir 800 mg orally five times daily for 7-10 days 2
  • Famciclovir 500 mg orally three times daily for 7 days 3

Timing of Treatment

• Antiviral therapy should be initiated as soon as possible, ideally within 72 hours of rash onset for maximum effectiveness 1, 4
• Recent evidence suggests that starting treatment even after 72 hours may still provide some benefit in reducing zoster-associated pain 5

Special Populations

• For immunocompromised patients with severe disease or complications, intravenous acyclovir 5 mg/kg every 8 hours is recommended until clinical resolution 6, 2
• Treatment duration may need to be extended if healing is incomplete after the initial course 2

Pain Management

• Pain control is a critical component of shingles management:
  • Appropriate analgesics should be used in combination with antiviral therapy 7
  • For neuropathic pain, consider adding low-dose tricyclic antidepressants (e.g., amitriptyline) 4, 7

Adjunctive Therapies

• Corticosteroids may provide modest benefits in reducing acute pain but do not significantly impact the development of postherpetic neuralgia 8
• Topical acyclovir is substantially less effective than oral therapy and is not recommended 2

Patient Education

• 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 6
• Patients should be informed about the possibility of postherpetic neuralgia as a complication 4

Common Pitfalls to Avoid

• 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
• Using topical antiviral medications instead of systemic therapy 2

Follow-up Recommendations

• Monitor for complete resolution of lesions; treatment may need to be extended if healing is incomplete after the initial course 2
• Early referral to pain management specialists should be considered for patients with severe or persistent pain 7
• Patients with ocular involvement (herpes zoster ophthalmicus) should be referred to an ophthalmologist to prevent rare but serious complications 4