Treatment of Shingles (Herpes Zoster)
The recommended first-line treatment for shingles is oral antiviral therapy with acyclovir, valacyclovir, or famciclovir, which should be initiated as soon as possible after diagnosis to reduce viral replication and prevent complications. 1, 2
First-Line Antiviral Therapy
- Acyclovir 800 mg orally 5 times daily for 7-10 days 1, 2
- Valacyclovir 1000 mg orally 3 times daily for 7 days 1, 3
- Famciclovir 500 mg orally 3 times daily for 7 days 2, 4
Treatment Timing and Considerations
- Antiviral therapy should be initiated within 72 hours of rash onset for maximum effectiveness 2, 5
- Valacyclovir and famciclovir offer better bioavailability and less frequent dosing compared to acyclovir, potentially improving adherence 1, 3
- Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 1, 4
Special Populations
- For immunocompromised patients with severe or disseminated disease, intravenous acyclovir is recommended 1, 6
- Temporary reduction in immunosuppressive medication should be considered in immunocompromised patients with disseminated or invasive herpes zoster 1
- HIV-infected patients with herpes zoster should receive famciclovir 500 mg twice daily for 7 days 2
Pain Management
- Appropriate analgesics should be used in combination with antiviral therapy 5, 4
- For neuropathic pain, consider adding tricyclic antidepressants (e.g., amitriptyline) or anticonvulsants 5, 4
- Capsaicin, lidocaine patches, and nerve blocks can be used in selected patients with persistent pain 5
Adjunctive Therapy
- Corticosteroids may provide modest benefits in reducing acute pain but do not significantly reduce the incidence of postherpetic neuralgia 7
- Corticosteroids should generally be avoided in immunocompromised patients due to increased risk of disseminated infection 1
Prevention of Complications
- Early antiviral treatment reduces the risk of postherpetic neuralgia, although evidence for complete prevention is limited 8
- Patients with ocular involvement should be referred to an ophthalmologist to prevent rare but serious complications 5
- The recombinant zoster vaccine (Shingrix) is recommended for adults aged 50 years and older to prevent future episodes of herpes zoster 1
Monitoring
- Monitor for complete healing of lesions 1
- Follow up for development of postherpetic neuralgia, especially in elderly patients and those with severe acute pain 5, 8
Common Pitfalls
- Delaying antiviral therapy beyond 72 hours significantly reduces effectiveness 2, 5
- Relying solely on topical treatments is ineffective for systemic disease 1, 4
- Underestimating pain management needs, particularly in elderly patients 5, 8
- Failing to recognize ocular involvement, which requires specialized care 5