What is the recommended treatment for shingles?

Recommended Treatment for Shingles (Herpes Zoster)

The recommended first-line treatment for herpes zoster (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 symptoms and prevent complications such as postherpetic neuralgia. 1, 2

Antiviral Therapy Options

• Valacyclovir: 1 gram orally three times daily for 7 days 1
• Famciclovir: Treatment should be initiated as soon as possible after diagnosis 3
• Acyclovir: 800 mg orally five times daily for 7 days 2, 4

Antiviral therapy is most effective when started within 72 hours of rash onset, but may still provide benefit when initiated later, especially in reducing the risk of postherpetic neuralgia 5.

Treatment Considerations

Patient Selection for Antiviral Therapy

• Urgent indications for antiviral therapy include:
  • Patients over 50 years of age 6
  • Herpes zoster in the head and neck area, especially zoster ophthalmicus 6
  • Immunocompromised patients 2
  • Severe zoster on the trunk or extremities 6

Dosing Advantages

• Valacyclovir and famciclovir offer more convenient dosing schedules compared to acyclovir, potentially improving patient adherence 7, 5
• Valacyclovir has been shown to alleviate zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir in comparative studies 5

Pain Management

• Acute pain should be managed with appropriate analgesics in combination with antiviral therapy 6
• For neuropathic pain, consider:
  • Tricyclic antidepressants (e.g., amitriptyline) 2, 6
  • Anticonvulsants for neuropathic pain control 2
  • Narcotic analgesics may be required for adequate pain control in severe cases 2

Special Considerations

Immunocompromised Patients

• For immunocompromised patients with severe disease or complications, intravenous acyclovir 5 mg/kg every 8 hours may be required 8
• Longer duration of therapy may be needed until clinical resolution is attained 8

Ocular Involvement

• Ocular involvement in herpes zoster can lead to serious complications and generally merits referral to an ophthalmologist 2

Corticosteroids

• The addition of corticosteroids to antiviral therapy may provide modest benefits in reducing acute pain but has not been shown to significantly reduce the incidence of postherpetic neuralgia 4
• Steroid recipients may experience more adverse events 4

Patient Education

• Lesions are contagious to individuals who have not had chickenpox; patients should avoid contact with susceptible individuals until lesions have crusted 8
• Antiviral medications are generally well-tolerated with common side effects including nausea, headache, and gastrointestinal disturbances 8

Common Pitfalls to Avoid

• Delayed treatment: Initiating antiviral therapy beyond 72 hours after rash onset may reduce effectiveness, though some benefit may still be observed 5
• Inadequate pain management: Undertreatment of acute pain may contribute to development of postherpetic neuralgia 2, 6
• Overlooking ocular involvement: Failure to recognize and appropriately manage ophthalmic zoster can lead to vision-threatening complications 2