Guidelines for Managing Shingles
Antiviral therapy should be initiated within 72 hours of rash onset as the primary treatment for shingles, with acyclovir 800 mg orally five times daily for 7-10 days being the standard regimen. 1, 2
Diagnosis and Initial Assessment
- Shingles (herpes zoster) is caused by reactivation of varicella zoster virus (VZV) that has remained dormant in dorsal root and cranial nerve ganglia after primary chickenpox infection 3
- Diagnosis is primarily clinical, based on the characteristic unilateral, dermatomal rash that progresses from maculopapular to vesicular lesions 3, 4
- Prodromal symptoms often include pain, burning, or discomfort in the affected dermatome 2-3 days before rash appears 4
Antiviral Treatment Options
First-line Therapy
- Antiviral medications should be started ideally within 72 hours of rash onset for maximum effectiveness 1, 4
- FDA-approved antiviral options include:
Special Considerations
- Treatment may be extended if healing is incomplete after 10 days of therapy 3
- Intravenous antivirals may be necessary for severe cases or immunocompromised patients 6
- For acyclovir-resistant cases, intravenous foscarnet or cidofovir can be used 6
Pain Management
- Pain control is a critical component of shingles management 3
- Approach to pain management:
- Appropriate analgesics should be used in combination with antiviral therapy 3
- For neuropathic pain, consider adding neuroactive agents such as amitriptyline 3, 7
- For severe pain or postherpetic neuralgia, stronger interventions may be needed including narcotics, tricyclic antidepressants, or anticonvulsants 7, 4
Special Populations
Immunocompromised Patients
- Patients with decreased immune function (HIV, chemotherapy, malignancies, chronic corticosteroid use) are at higher risk for developing shingles 7
- More aggressive treatment may be needed as these patients can develop more severe disease with potential for cutaneous dissemination and visceral involvement 8
- Intravenous antivirals should be considered for severe cases 6
Pregnant Women
- VZIG (varicella zoster immune globulin) is recommended for VZV-susceptible pregnant women within 96 hours after exposure to VZV 6
- If oral acyclovir is used, VZV serology should be performed to determine if the patient is already seropositive 6
Children
- The recommendations for preventing initial disease and recurrence in adults generally apply to children as well 6
- HIV-infected children who are asymptomatic and not immunosuppressed should receive live attenuated varicella vaccine at 12-15 months of age or later 6
Prevention of Complications
Postherpetic Neuralgia
- Postherpetic neuralgia (PHN) is the most common complication, occurring in about 20% of patients 4
- Early antiviral therapy may reduce the risk and severity of PHN 3, 4
- For established PHN, treatment options include:
Ocular Involvement
- Herpes zoster ophthalmicus requires urgent attention and referral to an ophthalmologist 7
- Complications can include keratitis, iridocyclitis, secondary glaucoma, and vision loss 8
Prevention
- The varicella zoster virus vaccine is recommended for adults 60 years and older to decrease the incidence of herpes zoster 4
- No drug has been proven to prevent the recurrence of shingles in HIV-infected persons 6
- Susceptible HIV-infected individuals should avoid exposure to persons with chickenpox or shingles 6
Common Pitfalls and Caveats
- Delaying antiviral therapy beyond 72 hours significantly reduces effectiveness 1, 4
- Topical acyclovir is substantially less effective than systemic therapy and is not recommended 6
- Corticosteroids may provide modest benefits in reducing acute pain but do not significantly impact the development of postherpetic neuralgia 3, 9
- Patients should be counseled that even with appropriate treatment, postherpetic neuralgia can still develop and may require additional management 7, 4