First-Line Treatment for Shingles
The first-line treatment for shingles (herpes zoster) is oral antiviral therapy with acyclovir or valacyclovir, which should be continued until all lesions have scabbed. 1
Recommended Antiviral Medications
- For uncomplicated herpes zoster, oral acyclovir or valacyclovir are the recommended first-line treatments 1
- Acyclovir 800 mg orally 5 times daily for 7-10 days is a standard treatment option 1
- Valacyclovir 1 gram 3 times daily for 7 days is an effective alternative with a more convenient dosing schedule 2
- Famciclovir 500 mg three times daily for 7 days is another effective option 3
Timing of Treatment
- Antiviral therapy should be initiated as soon as possible after diagnosis, ideally within 72 hours of rash onset 1, 4
- Treatment initiated within 48 hours of rash onset provides greater benefits 3
- Starting treatment later than 72 hours after rash onset may still be beneficial, especially in reducing zoster-associated pain 5
Special Considerations for Immunocompromised Patients
- For disseminated or invasive herpes zoster in immunocompromised patients, intravenous acyclovir is recommended 1
- A temporary reduction in immunosuppressive medication should be considered in immunocompromised patients with disseminated or invasive herpes zoster 1
- Kidney transplant recipients with uncomplicated herpes zoster should receive oral acyclovir or valacyclovir 6
Comparative Efficacy of Antivirals
- Valacyclovir has better bioavailability than acyclovir, potentially improving efficacy 5
- Famciclovir has been shown to reduce the duration of postherpetic neuralgia compared to placebo 7
- In some studies, famciclovir provided earlier pain relief compared to valacyclovir, particularly in patients aged 50 years or older 8
Prevention of Complications
- Prompt antiviral treatment reduces the risk of postherpetic neuralgia, the most common complication of herpes zoster 7, 4
- The recombinant zoster vaccine (Shingrix) is recommended for adults aged 50 years and older to prevent herpes zoster and its complications 1
- For varicella-susceptible patients exposed to individuals with active varicella zoster infection, varicella zoster immunoglobulin within 96 hours of exposure is recommended 1
Treatment Caveats
- Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 1
- Monitor for complete healing of lesions and resolution of pain 1
- Patients with persistent pain after resolution of the rash may require additional treatment for postherpetic neuralgia, including tricyclic antidepressants, anticonvulsants, or topical agents 4