Treatment of Shingles (Herpes Zoster)
For immunocompetent patients with shingles, oral antiviral therapy with acyclovir 800 mg five times daily for 7-10 days is the recommended first-line treatment, ideally initiated within 72 hours of rash onset. 1
First-Line Antiviral Options
- Acyclovir 800 mg orally five times daily for 7-10 days 1
- Valacyclovir 1 g orally three times daily for 7 days 2
- Famciclovir 500 mg orally every 8 hours for 7 days 3
Treatment Algorithm
Step 1: Initiate antiviral therapy as soon as possible
- Start treatment within 72 hours of rash onset for optimal effectiveness 1, 4
- Even if beyond 72 hours, antivirals may still provide benefit 2
Step 2: Select appropriate antiviral based on patient factors
- For patients who need less frequent dosing (better compliance): valacyclovir or famciclovir 5, 2
- For patients with renal impairment: adjust dose based on creatinine clearance 3
Step 3: Manage pain
- Acute pain: NSAIDs or acetaminophen for mild pain; consider short-term opioids for severe pain 4
- For postherpetic neuralgia: consider tricyclic antidepressants or anticonvulsants in low doses 4
Special Populations
Immunocompromised Patients
- Intravenous acyclovir 5-10 mg/kg every 8 hours for 5-7 days or until clinical resolution 6, 7
- Monitor for acyclovir resistance, especially if lesions persist during treatment 6
- For acyclovir-resistant cases, consider foscarnet 40 mg/kg IV every 8 hours until clinical resolution 6, 7
Severe Cases
- Consider hospitalization for patients with disseminated infection, pneumonitis, hepatitis, or central nervous system complications 6
- Intravenous acyclovir is indicated for these severe presentations 6, 1
Common Pitfalls to Avoid
- Using topical acyclovir is substantially less effective than oral therapy and is not recommended 1
- Inadequate dosing or duration of therapy may lead to treatment failure and increased risk of complications 1
- Failing to recognize and appropriately manage herpes zoster in immunocompromised patients, who require more aggressive therapy 7
- Delaying treatment beyond 72 hours significantly reduces the effectiveness of antiviral therapy 4
Follow-up Recommendations
- Monitor for complete resolution of lesions; treatment may need to be extended if healing is incomplete after the initial course 1
- Watch for development of postherpetic neuralgia, especially in elderly patients 4, 8
- If symptoms worsen despite treatment, consider secondary bacterial infection or resistance to antiviral medication 7
Evidence Quality and Considerations
The recommendation for acyclovir as first-line therapy is based on well-established guidelines from the Centers for Disease Control and Prevention 1. Valacyclovir and famciclovir have demonstrated similar efficacy to acyclovir with the advantage of less frequent dosing, which may improve patient compliance 5, 2. For immunocompromised patients, intravenous acyclovir is strongly recommended based on CDC guidelines 6, 7.