What is the recommended treatment for herpes zoster?

Treatment of Herpes Zoster

For uncomplicated herpes zoster, initiate oral valacyclovir 1 gram three times daily for 7 days, starting within 72 hours of rash onset. 1

First-Line Treatment for Uncomplicated Disease

Oral antiviral therapy is the cornerstone of herpes zoster management and should be started as soon as possible, ideally within 72 hours of rash onset. 1, 2 The recommended options include:

• Valacyclovir 1 gram orally three times daily for 7 days (preferred due to better bioavailability and convenient dosing) 1, 3
• Acyclovir 800 mg orally five times daily for 7 days (alternative option, though requires more frequent dosing) 1, 4
• Famciclovir (offers better bioavailability than acyclovir with less frequent dosing) 4, 5

Treatment within 72 hours significantly reduces the duration and severity of acute pain, accelerates cutaneous healing, and may prevent complications. 2, 5 Delayed initiation beyond 72 hours reduces effectiveness. 1

Treatment for Severe or Complicated Disease

For disseminated, multi-dermatomal, ophthalmic, visceral, or complicated herpes zoster, use intravenous acyclovir 5-10 mg/kg every 8 hours. 6, 1, 3

• Continue IV therapy until clinical improvement occurs, then switch to oral therapy to complete the treatment course 1
• Treatment should continue for a minimum of 7-10 days and until clinical resolution is attained 6, 1
• If new lesions continue to form or healing is incomplete, extend treatment beyond 7 days 1

Management in Immunocompromised Patients

All immunocompromised patients with herpes zoster require antiviral treatment regardless of timing. 6, 4

• For uncomplicated disease: oral valacyclovir or acyclovir at standard doses 3
• For disseminated or invasive disease: IV acyclovir 5-10 mg/kg every 8 hours 1, 3
• Temporarily discontinue or reduce immunosuppressive therapy in severe cases of disseminated VZV infection 6, 1, 3
• Immunosuppression may be restarted after the patient has commenced anti-VZV therapy and skin vesicles have resolved 6
• Monitor closely for dissemination and visceral complications 3, 4
• Consider longer treatment duration if healing is delayed 1

Special Populations and Urgent Indications

Systemic antiviral therapy is urgently indicated in: 2

• All patients aged >50 years (regardless of location or severity) 2, 5
• Herpes zoster in the head and neck area at any age, especially zoster ophthalmicus 2
• Severe herpes zoster on trunk or extremities 2
• Immunosuppressed patients at any age 2
• Patients with severe atopic dermatitis or eczema 2

Post-Exposure Prophylaxis

For varicella-susceptible patients exposed to active VZV infection: 1, 3

• Administer varicella zoster immunoglobulin within 96 hours of exposure (preferred) 1, 3
• If immunoglobulin is unavailable or >96 hours have passed: give a 7-day course of oral acyclovir beginning 7-10 days after exposure 1, 3

Acyclovir-Resistant Cases

For suspected acyclovir-resistant herpes zoster, use foscarnet 40 mg/kg IV every 8 hours. 1 Acyclovir-resistant isolates are routinely resistant to ganciclovir as well. 6

Critical Caveats

• Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 3
• Treatment does not eradicate latent virus but controls symptoms and reduces complications 3
• Antiviral therapy alone does not reliably prevent postherpetic neuralgia; consider concurrent pain management with analgesics and neuroactive agents (e.g., amitriptyline) 2
• Corticosteroids may shorten acute pain duration but have no essential effect on postherpetic neuralgia development 2