What is the recommended treatment for a patient presenting with shingles?

Treatment of Shingles (Herpes Zoster)

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 at the earliest sign or symptom of shingles and within 72 hours of rash onset for optimal effectiveness. 1, 2

First-Line Antiviral Options

• Valacyclovir 1 gram orally 3 times daily for 7 days is the recommended first-line treatment due to its convenient dosing schedule and good bioavailability 1, 2
• Alternative options include:
  • Acyclovir 800 mg orally 5 times daily for 7-10 days 3
  • Famciclovir 500 mg orally 3 times daily for 7 days 4
• Antiviral therapy should be initiated as soon as possible, ideally within 72 hours of rash onset, although benefits may still occur when started later 1, 5

Special Populations

• For immunocompromised patients with uncomplicated herpes zoster, oral antiviral therapy is still appropriate 1
• For disseminated or invasive disease in immunocompromised patients:
  • Intravenous acyclovir 5 mg/kg every 8 hours is recommended 1, 6
  • Consider temporary reduction in immunosuppressive medication 1
• For patients with herpes zoster ophthalmicus (eye involvement), prompt referral to an ophthalmologist is warranted alongside antiviral therapy 7

Treatment Considerations

• Therapy is most effective when started within 48-72 hours of rash onset 2, 8
• Treatment should continue until all lesions have scabbed over, which typically occurs in 7-10 days 1
• Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 3

Pain Management

• Acute pain management is an important component of shingles treatment:
  • For mild pain: acetaminophen or NSAIDs 7
  • For moderate to severe pain: short-term opioid analgesics may be necessary 7
• For postherpetic neuralgia (pain persisting >90 days after rash onset):
  • First-line options include tricyclic antidepressants, gabapentin, or pregabalin 8
  • Topical options include lidocaine patches or capsaicin 8

Prevention

• The recombinant zoster vaccine (Shingrix) is recommended for adults aged 50 years and older to prevent herpes zoster, regardless of prior episodes 1
• For varicella-susceptible individuals exposed to active VZV infection:
  • Varicella zoster immunoglobulin within 96 hours of exposure is recommended 1
  • If immunoglobulin is not available or more than 96 hours have passed, a 7-day course of oral acyclovir beginning 7-10 days after exposure is recommended 1

Common Pitfalls to Avoid

• Delaying antiviral therapy beyond 72 hours after rash onset reduces effectiveness 3
• Inadequate dosing or duration of therapy may lead to treatment failure and increased risk of complications 3
• Failing to recognize and appropriately manage herpes zoster in immunocompromised patients, who require more aggressive therapy 3
• Using topical antiviral therapy alone, which is substantially less effective than oral therapy 3

Follow-up Recommendations

• Monitor for complete resolution of lesions; treatment may need to be extended if healing is incomplete after the initial course 3
• Watch for development of postherpetic neuralgia, which occurs in approximately 20% of patients 8
• Consider vaccination with recombinant zoster vaccine after recovery to prevent future episodes 1