What is the recommended treatment for Herpes zoster?

Treatment of Herpes Zoster (Shingles)

The recommended first-line treatment for uncomplicated herpes zoster is oral antiviral therapy with valacyclovir 1 gram three times daily for 7 days, which should be initiated as soon as herpes zoster is diagnosed. 1

First-Line Antiviral Options

• Valacyclovir 1 gram orally three times daily for 7 days 1
• Famciclovir 500 mg orally every 8 hours for 7 days 2
• Acyclovir 800 mg orally five times daily for 7 days 1

Treatment Algorithm Based on Patient Presentation

Uncomplicated Herpes Zoster in Immunocompetent Patients

• Initiate antiviral therapy within 72 hours of rash onset for optimal efficacy 3, 4
• Valacyclovir and famciclovir are preferred over acyclovir due to better bioavailability and less frequent dosing requirements 5
• Continue treatment until all lesions have scabbed 3

Severe or Disseminated Disease

• For disseminated or invasive herpes zoster, use intravenous acyclovir 5-10 mg/kg every 8 hours 1
• Switch to oral therapy once clinical improvement occurs 1
• Consider temporary reduction in immunosuppressive medication if applicable 1

Immunocompromised Patients

• Intravenous acyclovir with temporary reduction in immunosuppressive medication is recommended for disseminated or invasive disease 3, 1
• High-dose IV acyclovir remains the treatment of choice for VZV infections in severely compromised hosts 3
• Monitor closely for dissemination and complications 1

Important Considerations

• Antiviral therapy is most effective when started within 72 hours of rash onset but may still provide benefit when started later 6
• Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 3
• Antiviral medications do not eradicate latent virus but help control symptoms and reduce complications 3
• For patients with suspected acyclovir-resistant herpes zoster, foscarnet 40 mg/kg body weight IV every 8 hours may be required 1

Prevention

• The CDC recommends the recombinant zoster vaccine (Shingrix) for adults aged 50 years and older regardless of prior episodes of herpes zoster 3
• Recombinant zoster vaccine is preferred over zoster vaccine live (ZVL) for the prevention of herpes zoster and related complications 7
• Vaccination is strongly recommended for patients 50 years of age and older without contraindications 7

Dosage Adjustment in Renal Impairment

• For patients with creatinine clearance 20-39 mL/min: famciclovir 500 mg every 24 hours 2
• For patients with creatinine clearance <20 mL/min: famciclovir 250 mg every 24 hours 2
• For hemodialysis patients: famciclovir 250 mg following each dialysis 2

Common Pitfalls and Caveats

• Delaying treatment beyond 72 hours after rash onset may reduce antiviral efficacy, though some benefit may still be observed 6
• Continuing treatment beyond 7 days may be necessary if new lesions continue to form or healing is incomplete 1
• Inadequate pain management can lead to decreased quality of life and development of postherpetic neuralgia 8
• Inappropriate dosing in patients with renal impairment can lead to acute renal failure 2

By following this treatment algorithm, clinicians can effectively manage herpes zoster infections while minimizing complications and improving patient outcomes.