What is the recommended treatment for shingles?

Treatment for Shingles

Start oral antiviral therapy immediately—ideally within 72 hours of rash onset—with valacyclovir 1 gram three times daily for 7 days, which is the most convenient first-line treatment for immunocompetent adults with herpes zoster. 1

Antiviral Therapy Selection

First-Line Options for Immunocompetent Adults

All three FDA-approved oral antivirals are effective and well-tolerated, with similar efficacy profiles:

• Valacyclovir 1 gram three times daily for 7 days is preferred due to convenient dosing and proven efficacy in reducing acute pain and postherpetic neuralgia duration 1, 2
• Famciclovir 500 mg three times daily for 7 days is equally effective with comparable outcomes to valacyclovir 3, 2
• Acyclovir 800 mg five times daily for 7 days is effective but requires more frequent dosing, which may reduce compliance 4, 5

The evidence shows valacyclovir accelerates resolution of zoster-associated pain significantly faster than acyclovir, making it a superior choice when compliance and pain control are priorities 2. Research demonstrates that twice-daily valacyclovir dosing (1.5 g) is as effective as three-times-daily regimens, though the FDA-approved dosing remains 1 gram three times daily 6.

Timing Considerations

• Initiate treatment within 48-72 hours of rash onset for maximum benefit 1, 4, 5
• Observational data suggests valacyclovir may still provide benefit when started beyond 72 hours, particularly for pain reduction, though earlier treatment is always preferable 2
• Begin therapy at the earliest sign or symptom (tingling, burning, pain) even before the rash fully develops 1, 3

Special Populations

Immunocompromised Patients

For severe disease or complications in immunocompromised patients, switch to intravenous acyclovir 5-10 mg/kg every 8 hours and continue until clinical resolution is achieved. 7, 8

• Treatment duration may need to be extended beyond the standard 7 days until complete clinical resolution 8
• This includes patients with HIV, those on chemotherapy, chronic corticosteroid users, or those with malignancies 4

Herpes Zoster Ophthalmicus

• Urgent antiviral therapy is indicated for any head and neck involvement, especially zoster ophthalmicus, due to risk of serious ocular complications 5
• Valacyclovir and acyclovir show similar efficacy for controlling ocular complications 2
• Ophthalmology referral is generally warranted 4

Absolute Indications for Antiviral Therapy

Treat these patients regardless of timing:

• All patients ≥50 years of age (highest risk for postherpetic neuralgia) 4, 5, 9
• Head and neck involvement at any age, particularly zoster ophthalmicus 5
• Immunocompromised patients 7, 8, 5
• Severe disease (extensive rash on trunk or extremities) 5
• Patients with severe atopic dermatitis or eczema 5

Pain Management

Acute Pain Control

• Combine antivirals with appropriately dosed analgesics plus a neuroactive agent (such as amitriptyline) for optimal pain control 5
• Common antiviral side effects include nausea, headache, and gastrointestinal disturbances, which are generally mild 7

Postherpetic Neuralgia Prevention

• The primary goal is achieving painlessness; antiviral therapy reduces both acute pain duration and postherpetic neuralgia incidence 5, 2
• Age and severity of initial pain are the strongest predictors of postherpetic neuralgia development (30% at 6 weeks, 15.9% at 6 months, 9% at 1 year in patients ≥50 years) 9
• Corticosteroids may modestly reduce acute pain but have no essential effect on postherpetic neuralgia development 4, 5

Established Postherpetic Neuralgia

If pain persists beyond rash resolution:

• Tricyclic antidepressants or anticonvulsants in low doses for neuropathic pain control 4
• Narcotics may be required for adequate pain control 4
• Topical capsaicin, lidocaine patches, or nerve blocks in selected cases 4
• Early referral to pain specialist for refractory cases 5

Patient Education and Infection Control

• Lesions are contagious to individuals who have not had chickenpox until all lesions have crusted over 7, 8
• Patients should avoid contact with pregnant women, newborns, and immunocompromised individuals during the contagious period 7, 8
• Antivirals are not a cure but significantly reduce symptom duration and complication risk 3, 4

Common Pitfalls

• Delaying treatment beyond 72 hours: While some benefit may still occur, efficacy is significantly reduced 4, 5
• Undertreating elderly patients: 50% of high-risk patients in community settings receive suboptimal treatment, often due to late presentation 9
• Using acyclovir when valacyclovir or famciclovir are available: The prodrugs offer better compliance and potentially superior pain outcomes 2, 9
• Failing to address pain aggressively: Pain management should be initiated simultaneously with antivirals, not as an afterthought 5