What is the recommended treatment for shingles?

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 with herpes zoster. 1

Antiviral Therapy for Immunocompetent Patients

The cornerstone of shingles treatment is oral antiviral medication, which should be initiated as early as possible:

First-Line Oral Antivirals (Choose One):

• Valacyclovir 1 gram three times daily for 7 days - This is the FDA-approved regimen and offers excellent efficacy with convenient dosing 1

• Famciclovir 500 mg three times daily for 7 days - Equally effective alternative with comparable outcomes to valacyclovir 2, 3

• Acyclovir 800 mg five times daily for 7 days - Effective but requires more frequent dosing, which may reduce compliance 4, 5

Timing of Antiviral Initiation:

• Optimal window: Within 48-72 hours of rash onset - This is when antivirals are most effective at reducing acute pain, accelerating rash healing, and preventing postherpetic neuralgia 1, 4, 5

• Beyond 72 hours may still provide benefit - Observational data suggests valacyclovir can still reduce zoster-associated pain duration even when started later, though earlier is always preferable 3

Key Benefits of Antiviral Treatment:

• Accelerates resolution of the rash 4, 5
• Reduces severity and duration of acute pain 3
• Decreases risk and duration of postherpetic neuralgia 4, 3
• Prevents complications, particularly in high-risk patients 5

Treatment for Immunocompromised Patients

For immunocompromised patients with severe disease or complications, use intravenous acyclovir 5-10 mg/kg every 8 hours until clinical resolution is achieved. 6, 7

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

Pain Management

Combine antivirals with appropriate analgesics and consider neuroactive agents for optimal pain control:

• Analgesics: Dose appropriately for the severity of pain; narcotics may be required for adequate control 4
• Neuroactive agents: Low-dose tricyclic antidepressants (e.g., amitriptyline) or anticonvulsants help control neuropathic pain 4, 5
• Topical agents: Capsaicin cream or lidocaine patches for localized pain relief 4
• Corticosteroids: May provide modest benefit in reducing acute pain but do not significantly prevent postherpetic neuralgia 4, 5

Special Situations Requiring Urgent Treatment

Certain presentations mandate immediate antiviral therapy regardless of timing:

• Age ≥50 years - Significantly increased risk of postherpetic neuralgia 5, 8
• Herpes zoster ophthalmicus (involvement of the eye or forehead) - Risk of serious ocular complications; consider ophthalmology referral 4, 5
• Head and neck involvement - Higher complication rates 5
• Severe rash on trunk or extremities 5
• Immunocompromised patients at any age 5
• Patients with severe atopic dermatitis or eczema 5

Patient Education and Infection Control

Counsel patients on contagion risk and appropriate precautions:

• Lesions are contagious to individuals who have not had chickenpox 6, 7
• Patients should avoid contact with susceptible individuals (pregnant women, immunocompromised persons, infants) until all lesions have crusted over 6, 7
• Antivirals are not a cure but significantly improve outcomes 2

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours - While some benefit may still occur, efficacy is significantly reduced 1, 5
• Undertreating elderly patients - 50% of high-risk elderly patients in community settings receive suboptimal treatment, often due to late presentation 8
• Using acyclovir when compliance is a concern - Five-times-daily dosing reduces adherence; valacyclovir or famciclovir are preferable 9, 5
• Inadequate pain management - Pain control should be aggressive from the outset to prevent chronic postherpetic neuralgia 4, 5
• Missing ocular involvement - Any periorbital or forehead involvement warrants ophthalmology evaluation 4

Adverse Effects

Oral antivirals are generally well-tolerated with the most common side effects being nausea, headache, and gastrointestinal disturbances 6, 3