From the Guidelines
Treatment for zoster lesions (shingles) should begin with antiviral medications as soon as possible after rash onset, ideally within 72 hours, with first-line options including valacyclovir, famciclovir, or acyclovir, as recommended by the most recent guidelines 1. The goal of treatment is to reduce morbidity, mortality, and improve quality of life by promoting faster healing, decreasing acute pain, and reducing the risk of postherpetic neuralgia.
- Valacyclovir (1000 mg three times daily for 7 days) and famciclovir (500 mg three times daily for 7 days) are preferred due to better bioavailability and simpler dosing schedules.
- Acyclovir (800 mg five times daily for 7-10 days) is also an option, particularly for patients who cannot tolerate valacyclovir or famciclovir.
- For pain management, acetaminophen or NSAIDs can be used initially, with gabapentin (starting at 300 mg daily and titrating up) or pregabalin for more severe pain, as supported by the guidelines 1.
- Topical treatments like calamine lotion or colloidal oatmeal baths can provide symptomatic relief, and keeping lesions clean and dry can prevent secondary bacterial infection.
- If the rash involves the eye (ophthalmic zoster), urgent ophthalmology referral is necessary, and for immunocompromised patients or those with severe disease, intravenous acyclovir may be required, as recommended by the guidelines 1.
- Patients should be advised to avoid contact with pregnant women who haven't had chickenpox, immunocompromised individuals, and newborns until lesions have crusted over, to prevent transmission of the virus, as suggested by the guidelines 1.
From the FDA Drug Label
Two randomized, double-blind trials, 1 placebo-controlled and 1 active-controlled, were conducted in 964 immunocompetent adults with uncomplicated herpes zoster. Treatment was initiated within 72 hours of first lesion appearance and was continued for 7 days In the placebo-controlled trial, 419 patients were treated with either famciclovir 500 mg three times daily (n=138), famciclovir 750 mg three times daily (n=135) or placebo (n=146). The median time to full crusting was 5 days among famciclovir 500 mg-treated patients as compared to 7 days in placebo-treated patients The times to full crusting, loss of vesicles, loss of ulcers, and loss of crusts were shorter for famciclovir 500 mg-treated patients than for placebo-treated patients in the overall study population.
Zoster lesions treatment: Famciclovir 500 mg three times daily for 7 days can be used to treat zoster lesions. The median time to full crusting is 5 days with famciclovir treatment, compared to 7 days with placebo.
- Key benefits:
- Shorter time to full crusting
- Shorter time to loss of vesicles, ulcers, and crusts
- Median duration of postherpetic neuralgia was shorter in patients treated with famciclovir 500 mg than in those treated with placebo (63 days and 119 days, respectively) 2
From the Research
Treatment Options for Zoster Lesions
- Oral antiviral agents, such as acyclovir, valacyclovir, and famciclovir, are the primary treatment for herpes zoster 3, 4, 5, 6, 7
- These agents can reduce the duration and intensity of zoster-associated pain, as well as the prevalence of postherpetic neuralgia 3, 4, 5, 6
- Valacyclovir and famciclovir have been shown to be at least as effective as acyclovir in controlling the symptoms of acute herpes zoster 4, 6
- The efficacy of antiviral therapy is highest when initiated within 72 hours of symptom onset 3, 4, 5
Dosage and Administration
- Acyclovir: 800 mg five times a day 6
- Valacyclovir: 900-1000 mg three times a day 6
- Famciclovir: 250 mg three times a day 6
- The choice of antiviral agent and dosage should be based on individual patient needs and medical history 6
Management of Postherpetic Neuralgia
- Tricyclic antidepressants, gabapentin, pregabalin, long-acting opioids, or tramadol may be used to treat postherpetic neuralgia 7
- Capsaicin cream or a lidocaine patch may be used as a second-line agent 7
- Immunization to prevent herpes zoster and postherpetic neuralgia is recommended for most adults 60 years and older 7