What is the recommended treatment for shingles?

Treatment for Shingles

The recommended treatment for shingles (herpes zoster) is valacyclovir 1 gram three times daily for 7 days, initiated at the earliest sign or symptom of herpes zoster and ideally within 48 hours of rash onset. 1

First-Line Antiviral Therapy

• Valacyclovir 1 gram three times daily for 7 days 1
• Famciclovir 500 mg three times daily for 7 days 2
• Acyclovir 800 mg five times daily for 7-10 days 3

Antiviral therapy should be initiated as soon as possible, ideally within 72 hours of rash onset, though treatment may still provide benefit when started later 4. Early treatment is most effective in:

• Reducing the duration of the acute phase
• Accelerating rash healing
• Decreasing the severity and duration of acute pain
• Potentially reducing the risk of postherpetic neuralgia 3, 5

Special Populations

• Immunocompromised patients: Intravenous acyclovir 5-10 mg/kg every 8 hours is recommended for severe herpes zoster or complications, with treatment duration potentially extended until clinical resolution 6, 7
• Patients with herpes zoster ophthalmicus: Require urgent systemic antiviral therapy and should be referred to an ophthalmologist to prevent rare but serious ocular complications 3, 5

Pain Management

• Appropriately dosed analgesics should be combined with antiviral therapy 5
• For neuropathic pain, consider:
  • Tricyclic antidepressants (e.g., amitriptyline) in low doses 3, 5
  • Anticonvulsants for pain control 3
  • Narcotics may be required for adequate pain control in severe cases 3

Patient Education and Precautions

• Patients should be advised that lesions are contagious to individuals who have not had chickenpox 6
• Contact with susceptible individuals should be avoided until lesions have crusted 7
• Common side effects of antiviral medications include nausea, headache, and gastrointestinal disturbances 6

Comparative Efficacy of Treatments

• Valacyclovir (1 gram three times daily) has been shown to alleviate zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 4
• Valacyclovir and famciclovir have similar efficacy in speeding resolution of acute herpes zoster rash and shortening the duration of postherpetic neuralgia 4
• The simpler dosing regimen of valacyclovir (three times daily) compared to acyclovir (five times daily) may improve patient compliance 8, 4

Role of Corticosteroids

• The addition of corticosteroids to antiviral therapy may provide modest benefits in reducing acute pain of herpes zoster 3
• However, corticosteroids have not shown significant effect on preventing postherpetic neuralgia 9
• Corticosteroid use should be carefully considered due to potential adverse effects 9

Treatment Pitfalls to Avoid

• Delaying antiviral therapy beyond 72 hours after rash onset may reduce treatment efficacy, though some benefit may still be observed 4
• Inadequate pain management can lead to decreased quality of life and increased risk of developing chronic pain 3
• Failure to recognize and appropriately treat herpes zoster in immunocompromised patients or those with ocular involvement can lead to severe complications 7, 3