Treatment of Shingles in Elderly Patients
Elderly patients with shingles should be treated with oral antiviral therapy—specifically valacyclovir 1000 mg three times daily for 7 days, famciclovir 500 mg three times daily for 7 days, or acyclovir 800 mg five times daily for 7 days—initiated within 72 hours of rash onset to reduce pain duration and prevent postherpetic neuralgia. 1, 2, 3
First-Line Antiviral Therapy
Oral antiviral agents are the cornerstone of treatment and should be started as soon as possible, ideally within 48-72 hours of rash onset. 1, 4 The three FDA-approved options are:
- Valacyclovir 1000 mg orally three times daily for 7 days 3, 5
- Famciclovir 500 mg orally three times daily for 7 days 6, 7
- Acyclovir 800 mg orally five times daily for 7 days 3, 8
Valacyclovir offers superior convenience with three-times-daily dosing and has been shown to accelerate pain resolution compared to acyclovir (median 38 days versus 51 days) and reduce the proportion of patients with pain persisting at 6 months (19.3% versus 25.7%). 5 Famciclovir similarly reduces postherpetic neuralgia duration by approximately 2 months in patients ≥50 years compared to placebo. 7
Treatment should continue until all lesions have scabbed. 9, 1
Critical Indications for Treatment
Systemic antiviral therapy is urgently indicated in all patients over age 50, regardless of lesion location or severity. 4 Additional urgent indications include:
- Herpes zoster involving the head and neck, especially zoster ophthalmicus 4
- Severe herpes zoster on trunk or extremities 4
- Immunosuppressed patients 4
- Disseminated or invasive disease 9, 1
Special Considerations for Elderly Patients
Elderly patients require dose adjustment based on renal function, as they are more likely to have reduced creatinine clearance. 3 For acyclovir, dosing should be reduced when creatinine clearance is <50 mL/min. 3
Elderly patients are at higher risk for CNS adverse events including somnolence, hallucinations, confusion, and coma with acyclovir. 3 They also experience longer duration of pain after healing compared to younger adults. 3
Nausea, vomiting, and dizziness are reported more frequently in elderly subjects receiving acyclovir. 3
Escalation to Intravenous Therapy
Intravenous acyclovir is recommended for disseminated or invasive herpes zoster, with temporary reduction in immunosuppressive medications if applicable. 9, 1 Treatment should continue at least until all lesions have scabbed. 9
Pain Management
Appropriately dosed analgesics combined with a neuroactive agent (such as amitriptyline) should be given together with antiviral therapy to achieve painlessness. 4 The intensity of pain therapy should match the intensity of pain experienced. 10
Corticosteroids may shorten acute zoster pain duration but have no essential effect on preventing postherpetic neuralgia development. 4 One study showed no added benefit of corticosteroids plus acyclovir over acyclovir alone. 8
Important Caveats
Topical antiviral therapy is substantially less effective than systemic therapy and should not be used. 1, 2
Antiviral medications do not eradicate latent virus but control symptoms and reduce complications. 1
Even in the absence of visible rash (zoster sine herpete), antiviral therapy should be initiated when suspected in elderly patients due to their higher risk for postherpetic neuralgia. 2
Prevention
The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes. 1 This is particularly important before initiating immunosuppressive therapies like JAK inhibitors. 9