Treatment of Shingles (Herpes Zoster)
The recommended first-line treatment for shingles is oral antiviral therapy with valacyclovir 1 gram three times daily for 7 days, which should be initiated within 72 hours of rash onset for optimal effectiveness. 1, 2
Antiviral Medication Options
- Valacyclovir: 1 gram orally three times daily for 7 days 1
- Famciclovir: 500 mg orally three times daily for 7 days 3
- Acyclovir: 800 mg orally five times daily for 7-10 days 2
Treatment Timing and Duration
- Antiviral therapy should be initiated as soon as possible, ideally within 72 hours of rash onset for maximum effectiveness 4, 5
- Treatment may be extended if healing is incomplete after the initial course 2
- Some evidence suggests that starting treatment after 72 hours may still provide benefit, particularly in reducing zoster-associated pain 6
Special Populations
Immunocompromised Patients
- More aggressive management is required, including potential use of intravenous acyclovir 5 mg/kg every 8 hours for severe cases 2
- HIV-infected patients with shingles require prompt antiviral therapy to prevent complications 7
Elderly Patients
- Antiviral therapy is particularly important in patients over 50 years of age due to higher risk of postherpetic neuralgia 4, 5
- Pain management should be addressed concurrently with antiviral therapy 8
Pain Management
- Acute pain during shingles should be treated with appropriate analgesics 8
- For postherpetic neuralgia (pain persisting >90 days after rash onset):
Common Pitfalls to Avoid
- Topical acyclovir is substantially less effective than oral therapy and is not recommended 2
- Inadequate dosing or duration of therapy may lead to treatment failure and increased risk of complications 2
- Delaying treatment beyond 72 hours significantly reduces effectiveness, though some benefit may still be obtained 4, 6
- Failing to address pain management concurrently with antiviral therapy 4, 8
Advantages of Valacyclovir and Famciclovir
- Valacyclovir and famciclovir have better bioavailability than acyclovir, allowing for less frequent dosing and potentially better compliance 9, 6
- Valacyclovir (1 gram three times daily) has been shown to alleviate zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 6
- Twice-daily dosing of valacyclovir (1.5 grams twice daily) has also been shown to be effective and may further improve compliance 9
Follow-up Recommendations
- Monitor for complete resolution of lesions; treatment may need to be extended if healing is incomplete after the initial course 2
- Patients should be evaluated for development of postherpetic neuralgia, especially those over 50 years of age 5
- Consider early referral to pain management for patients with severe acute pain or those at high risk for postherpetic neuralgia 4