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, famciclovir 500 mg three times daily for 7 days, or acyclovir 800 mg five times daily for 7-10 days. 1, 2, 3
First-Line Antiviral Options
All three FDA-approved oral antivirals demonstrate equivalent efficacy for treating herpes zoster, so selection depends primarily on dosing convenience and patient compliance:
Valacyclovir 1 gram three times daily for 7 days is the preferred option due to superior pharmacokinetics and simpler dosing compared to acyclovir 1, 4
Famciclovir 500 mg three times daily for 7 days offers comparable efficacy to valacyclovir with similar three-times-daily dosing 2, 4
Acyclovir 800 mg five times daily for 7-10 days remains effective but requires more frequent dosing, which may reduce compliance 3
Avoid topical acyclovir entirely—it is substantially less effective than oral therapy and should not be used 3
Timing of Treatment Initiation
Antiviral therapy is most effective when started within 48-72 hours of rash onset 3, 5
However, treatment initiated beyond 72 hours may still provide benefit for pain reduction, so do not withhold antivirals even in late presenters 4
Begin treatment at the earliest sign or symptom (tingling, burning, pain) before the rash fully develops when possible 1, 2
Special Populations Requiring Modified Treatment
Immunocompromised patients with severe disease, disseminated herpes zoster, or complications require more aggressive management:
Administer intravenous acyclovir 5-10 mg/kg every 8 hours until clinical resolution is achieved 6, 3, 7
Treatment duration may need to be extended beyond the standard 7-day course until complete lesion healing occurs 3, 7
Consider discontinuing immunosuppressive therapy in severe cases of disseminated herpes zoster 3
Pain Management
Adequate analgesia is critical alongside antiviral therapy:
Prescribe appropriately dosed analgesics, including narcotics if necessary for severe pain 8
Add neuroactive agents such as low-dose tricyclic antidepressants (amitriptyline) or anticonvulsants for neuropathic pain control 8
Topical lidocaine patches or capsaicin may provide additional relief in selected patients 8
Role of Corticosteroids
Adding oral corticosteroids (prednisolone 40 mg daily, tapered over 3 weeks) provides modest benefits in reducing acute zoster pain but does not prevent postherpetic neuralgia 9
The slight benefit in acute pain reduction must be weighed against increased adverse events with steroid use 9
Corticosteroids are not routinely recommended but may be considered for severe acute pain in immunocompetent patients 9
Urgent Indications for Antiviral Therapy
Certain presentations mandate immediate antiviral treatment:
All patients over 50 years of age regardless of rash location 5
Herpes zoster ophthalmicus or any head/neck involvement due to risk of serious ocular and neurologic complications—consider ophthalmology referral 8, 5
Severe herpes zoster on trunk or extremities 5
Any immunocompromised patient 5
Patients with severe atopic dermatitis or eczema 5
Common Pitfalls to Avoid
Inadequate dosing or premature discontinuation leads to treatment failure and increased complication risk 3
Failing to recognize immunocompromised patients who require IV therapy rather than oral antivirals 3
Delaying treatment while awaiting laboratory confirmation—diagnosis is clinical and treatment should begin immediately 5
Using topical acyclovir which is ineffective 3
Patient Education and Infection Control
Inform patients that lesions remain contagious to individuals who have not had chickenpox until all lesions have fully crusted over 6, 7
Advise avoiding contact with pregnant women, newborns, and immunocompromised individuals until lesions crust 6, 7
Counsel that antivirals are not a cure but reduce severity and duration of symptoms 2
Follow-Up Monitoring
Monitor for complete lesion resolution; extend treatment duration if healing is incomplete after the initial 7-day course 3
Assess for development of postherpetic neuralgia, particularly in patients over 50 years of age 8
Refer patients with persistent severe pain to pain management specialists early rather than waiting for prolonged suffering 8