What is the treatment for extensive herpes zoster (shingles)?

From the Guidelines

Extensive herpes zoster treatment should prioritize antiviral medications, such as valacyclovir, famciclovir, or acyclovir, to reduce the risk of postherpetic neuralgia and other complications. The treatment approach should be guided by the severity of the disease and the patient's immune status.

Key Considerations

• Antiviral therapy should be initiated as soon as possible, ideally within 72 hours of rash onset, to maximize its effectiveness 1.
• The choice of antiviral medication depends on the patient's renal function, tolerance, and potential interactions with other medications.
• Pain management is crucial and may involve a combination of acetaminophen, NSAIDs, gabapentin, pregabalin, and topical treatments like lidocaine patches or capsaicin cream.
• In severe cases, especially in immunocompromised patients or those with ophthalmic involvement, hospitalization and intravenous acyclovir may be necessary 1.
• Corticosteroids may be considered in select cases to reduce inflammation and pain, but their use should be carefully weighed against potential risks.

Treatment Options

• Valacyclovir (1000 mg three times daily) or famciclovir (500 mg three times daily) for 7-10 days are recommended as first-line treatments for extensive herpes zoster.
• Acyclovir (800 mg five times daily) for 7-10 days is an alternative option, especially in patients with renal impairment.
• Intravenous acyclovir (10 mg/kg every 8 hours) may be necessary for severe cases or in immunocompromised patients.

Important Considerations

• Early and aggressive treatment is crucial to reduce the risk of postherpetic neuralgia and other complications.
• Patients with ophthalmic involvement or immunocompromised status require close monitoring and potentially more aggressive treatment.
• The treatment approach should be individualized based on the patient's specific needs and medical history.

From the FDA Drug Label

VALTREX is indicated for the treatment of herpes zoster (shingles) in immunocompetent adults. The efficacy of VALTREX when initiated more than 72 hours after the onset of rash and the efficacy and safety of VALTREX for treatment of disseminated herpes zoster have not been established.

Extensive herpes zoster treatment is indicated for immunocompetent adults, but the efficacy of treatment when initiated more than 72 hours after the onset of rash has not been established 2.

There are no data on treatment initiated more than 72 hours after onset of zoster rash Patients should be advised to initiate treatment as soon as possible after a diagnosis of herpes zoster.

Similarly, for famciclovir, extensive herpes zoster treatment should be initiated as soon as possible after diagnosis, but there are no data on treatment initiated more than 72 hours after onset of zoster rash 3.

From the Research

Extensive Herpes Zoster Treatment

• The treatment of herpes zoster involves the use of antiviral drugs such as valaciclovir, aciclovir, and famciclovir 4, 5, 6, 7.
• Valaciclovir has been shown to be at least as effective as aciclovir in controlling the symptoms of acute herpes zoster, and it alleviates zoster-associated pain and postherpetic neuralgia significantly faster than aciclovir 4, 6.
• The recommended regimen for the treatment of herpes zoster is valaciclovir 1000 mg three times daily for 7 days, which is well tolerated with nausea and headache being the most commonly reported adverse events 4, 6.
• Starting treatment later than 72 hours after rash onset did not significantly reduce the beneficial effect of valaciclovir on duration of zoster-associated pain, but treatment should ideally be given as soon as possible after symptoms appear 4.
• Adjunct medications such as opioid analgesics, tricyclic antidepressants, or corticosteroids may relieve the pain associated with acute herpes zoster, and evidence supports treating postherpetic neuralgia with tricyclic antidepressants, gabapentin, pregabalin, long-acting opioids, or tramadol 5, 8.

Treatment Options

• Valaciclovir is a well-tolerated first-line therapy with an established place in the treatment of immunocompetent patients with herpes zoster 4, 6, 7.
• Famciclovir is also an effective treatment option for herpes zoster, with similar efficacy to valaciclovir in speeding resolution of acute herpes zoster rash and shortening the duration of postherpetic neuralgia 4, 7.
• Aciclovir is an alternative treatment option, but it has a lower oral bioavailability than valaciclovir and requires more frequent dosing 4, 6.

Prevention and Management

• Immunization to prevent herpes zoster and postherpetic neuralgia is recommended for most adults 60 years and older 5.
• A stepwise management approach for both acute neuralgia and postherpetic neuralgia is proposed, taking into account the patient's age, frailty, co-morbidities, and polypharmacy 8.