What is the recommended treatment for shingles?

Recommended Treatment for Shingles

The recommended treatment for shingles (herpes zoster) is oral antiviral therapy with valacyclovir 1 gram three times daily for 7 days, initiated within 72 hours of rash onset for optimal effectiveness. 1

First-Line Antiviral Therapy Options

• Valacyclovir: 1 gram three times daily for 7 days 1
• Famciclovir: 500 mg three times daily for 7 days 2, 3
• Acyclovir: 800 mg five times daily for 7 days 4

Timing of Treatment

• Antiviral therapy should be initiated as soon as possible after diagnosis of herpes zoster 2
• Treatment is most effective when started within 48-72 hours of rash onset 1, 4
• While early treatment is optimal, some evidence suggests benefit may still occur when treatment is initiated beyond 72 hours, particularly in patients with ongoing new vesicle formation 5

Special Populations

• Immunocompromised patients: For severe disease or complications, intravenous acyclovir 5 mg/kg every 8 hours may be required until clinical resolution 6
• Patients with ophthalmic involvement: Require urgent antiviral therapy and should be referred to an ophthalmologist 4, 3
• Patients over 50 years: Should always receive antiviral therapy due to higher risk of postherpetic neuralgia 3, 5

Medication Selection Considerations

• Valacyclovir and famciclovir have better bioavailability than acyclovir, allowing for less frequent dosing and potentially better compliance 7, 8
• All antiviral medications are generally well-tolerated with common side effects including nausea, headache, and gastrointestinal disturbances 6
• Brivudin (where available) offers simplified once-daily dosing but is not FDA-approved in the US 3

Pain Management

• Adequate pain control is essential and may require:
  • Appropriate analgesics based on pain severity 3
  • Consider adding a neuroactive agent (e.g., amitriptyline) for neuropathic pain 3
  • For severe pain or postherpetic neuralgia, tricyclic antidepressants, anticonvulsants, or topical agents may be needed 4

Patient Education

• Lesions are contagious to individuals who have not had chickenpox until they have crusted over 6
• Patients should avoid contact with susceptible individuals (particularly immunocompromised persons, pregnant women, and those without history of chickenpox) 6
• Explain that early treatment can reduce the risk of postherpetic neuralgia, particularly in older adults 5, 8

Common Pitfalls to Avoid

• Delayed treatment: Many patients present after 72 hours of rash onset, reducing treatment efficacy 5
• Inadequate dosing: Using lower doses than recommended may reduce effectiveness 3
• Insufficient pain management: Pain control should be addressed aggressively to improve quality of life 3
• Missing ophthalmic involvement: Always check for eye involvement as this requires urgent treatment and specialist referral 4