What is the first line treatment for shingles?

First-Line Treatment for Shingles

For uncomplicated herpes zoster (shingles), oral acyclovir or valacyclovir are the recommended first-line treatments, which should be continued until all lesions have scabbed. 1

Treatment Recommendations

Uncomplicated Herpes Zoster

• Oral antiviral therapy should be initiated as soon as possible after diagnosis, ideally within 72 hours of rash onset 1, 2
• Recommended first-line treatment options include:
  • Valacyclovir 1 gram three times daily for 7 days 1, 3
  • Acyclovir 800 mg five times daily for 7 days 1, 4
  • Famciclovir 500 mg three times daily for 7 days 1, 5

Disseminated or Invasive Herpes Zoster

• Intravenous acyclovir is recommended for disseminated or invasive herpes zoster 1
• A temporary reduction in immunosuppressive medication should be considered in immunocompromised patients 1

Clinical Considerations

Timing of Treatment

• Treatment is most effective when started within 48 hours of rash onset 3, 2
• However, treatment may still be beneficial when initiated after 72 hours, especially in patients with ongoing new lesion formation, immunocompromised status, or severe pain 6

Medication Selection Factors

• Valacyclovir and famciclovir offer better bioavailability and less frequent dosing compared to acyclovir, potentially improving adherence 1, 6
• Famciclovir has been shown in some studies to provide earlier pain relief compared to valacyclovir, particularly in patients 50 years or older 7
• All three medications have comparable efficacy in resolving cutaneous lesions 6

Special Populations

• For immunocompromised patients with uncomplicated herpes zoster, oral antiviral therapy at standard doses is recommended 1
• For kidney transplant recipients with uncomplicated herpes zoster, oral acyclovir or valacyclovir is recommended 1
• Higher doses or intravenous therapy may be required for severe cases in immunocompromised patients 1

Prevention of Complications

• Prompt antiviral therapy can reduce the risk of postherpetic neuralgia, the most common complication of herpes zoster 8, 2
• Famciclovir has been shown to reduce the duration of postherpetic neuralgia compared to placebo 8
• Valacyclovir has been shown to alleviate zoster-associated pain and postherpetic neuralgia faster than acyclovir 6

Common Pitfalls and Caveats

• Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 1
• Extending treatment beyond 7 days generally provides no additional benefit unless lesions are still forming 6
• Monitor for complete healing of lesions; treatment should continue until all lesions have scabbed 1
• Antiviral medications do not eradicate latent virus but help control symptoms and reduce complications 1

Prevention Strategies

• The recombinant zoster vaccine (Shingrix) is recommended for adults aged 50 years and older to prevent future episodes of herpes zoster 1, 2
• For varicella-susceptible patients exposed to individuals with active varicella zoster infection, varicella zoster immunoglobulin within 96 hours of exposure is recommended 1