What is the recommended treatment for shingles?

Treatment of Shingles (Herpes Zoster)

The recommended treatment for shingles is oral valacyclovir 1 gram three times daily for 7 days, initiated within 48 hours of rash onset for optimal effectiveness. 1

First-Line Antiviral Therapy

• Valacyclovir 1 gram three times daily for 7 days is the FDA-approved dosage for herpes zoster treatment 1
• Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of rash onset 1, 2
• Alternative antiviral options include:
  • Acyclovir 800 mg five times daily for 7 days 2, 3
  • Famciclovir 500 mg three times daily for 7 days 4
  • Brivudin once daily for 7 days (where available; offers simpler dosing regimen) 2

Special Populations

• For immunocompromised patients with severe disease or complications:
  • Intravenous acyclovir 5-10 mg/kg every 8 hours is recommended 5, 6
  • Treatment duration may need to be extended until clinical resolution is achieved 6
  • More intensive monitoring and supportive care may be required 5

Pain Management

• Pain control is a critical component of shingles management 2
• Approach should include:
  • Appropriate analgesics based on pain severity 2
  • Consider adding neuroactive agents such as amitriptyline for neuropathic pain 2
  • For severe pain, early referral to a pain specialist may be beneficial 2

Patient Education and Infection Control

• Patients should be advised that lesions are contagious to individuals who have not had chickenpox 5, 6
• Avoid contact with susceptible individuals (especially immunocompromised persons, pregnant women, and newborns) until lesions have crusted 5
• Explain expected course of illness and importance of completing the full antiviral regimen 2

Common Pitfalls and Caveats

• Delaying antiviral therapy beyond 72 hours after rash onset significantly reduces treatment efficacy, though some benefit may still be observed 4
• Adding corticosteroids to antiviral therapy provides only modest benefits in reducing acute pain and does not significantly impact postherpetic neuralgia development 3
• Antiviral medications are generally well-tolerated with common side effects including nausea, headache, and gastrointestinal disturbances 5
• Ocular involvement in herpes zoster can lead to serious complications and generally warrants ophthalmology referral 2

Treatment Considerations for Postherpetic Neuralgia

• Early and aggressive antiviral therapy may help reduce the risk of postherpetic neuralgia 4
• For established postherpetic neuralgia, treatment options include:
  • Tricyclic antidepressants or anticonvulsants (often at low doses) 7
  • Topical agents such as capsaicin or lidocaine patches 7
  • Narcotic analgesics may be required for adequate pain control in severe cases 7