Treatment of Shingles (Herpes Zoster)
Start oral antiviral therapy with valacyclovir 1 gram three times daily for 7 days, ideally within 48-72 hours of rash onset, for all immunocompetent patients over 50 years of age and those with head/neck involvement at any age. 1
Antiviral Therapy
Standard Treatment for Immunocompetent Patients
- Valacyclovir 1 gram three times daily for 7 days is the recommended regimen, initiated at the earliest sign or symptom of herpes zoster and most effective when started within 48 hours of rash onset 1
- Alternative dosing of valacyclovir 1.5 grams twice daily has demonstrated equivalent safety and efficacy, with the advantage of improved compliance due to simpler dosing 2
- Treatment can be given without regard to meals 1
Timing of Initiation
- Antiviral therapy should ideally be started within 48-72 hours of rash onset for maximum effectiveness 3, 4
- However, treatment initiated beyond 72 hours may still provide benefit for reducing zoster-associated pain duration, so do not withhold therapy in late presenters 5
Immunocompromised Patients
- For immunocompromised patients with severe disease or complications, use intravenous acyclovir 5-10 mg/kg every 8 hours 6, 7
- Continue IV therapy until clinical resolution is achieved, which may require prolonged treatment duration beyond the standard 7 days 7
Specific Indications for Antiviral Treatment
Urgent Indications (Must Treat)
- All patients ≥50 years of age regardless of location 4
- Herpes zoster in the head and neck area at any age, especially zoster ophthalmicus 4
- Severe herpes zoster on trunk or extremities 4
- All immunosuppressed patients 4
- Patients with severe atopic dermatitis or eczema 4
Relative Indications
- Patients <50 years with zoster on trunk or extremities have only relative indications for treatment 4
Pain Management
Acute Pain Control
- Combine appropriately dosed analgesics with a neuroactive agent (such as amitriptyline) alongside antiviral therapy 4
- Narcotics may be required for adequate pain control in patients with postherpetic neuralgia 3
Adjunctive Corticosteroids
- Oral corticosteroids may provide modest benefits in reducing acute zoster pain but have no essential effect on preventing postherpetic neuralgia 3, 4
Postherpetic Neuralgia Management
- Tricyclic antidepressants or anticonvulsants in low dosages help control neuropathic pain 3
- Capsaicin cream, lidocaine patches, and nerve blocks can be used in selected patients 3
- Early referral to a pain specialist is recommended for difficult cases 4
Special Considerations
Ocular Involvement
- Herpes zoster ophthalmicus can lead to serious complications and generally merits referral to an ophthalmologist 3
Infection Control
- Advise patients that lesions are contagious to individuals who have not had chickenpox 6
- Patients should avoid contact with susceptible individuals until all lesions have crusted over 7
Common Pitfalls to Avoid
- Do not withhold treatment in patients presenting after 72 hours, as they may still benefit from antiviral therapy 5
- Antiviral medications are generally well-tolerated, with common side effects including nausea, headache, and gastrointestinal disturbances 6
- In observational studies, only 50% of high-risk patients received appropriate antiviral therapy, mainly due to late presentation beyond 72 hours—this represents suboptimal care 8