Treatment of Shingles
Start oral antiviral therapy immediately upon diagnosis, ideally within 72 hours of rash onset, with valacyclovir 1000 mg three times daily for 7 days, famciclovir 500 mg three times daily for 7 days, or acyclovir 800 mg five times daily for 7 days. 1, 2, 3
Antiviral Therapy Selection
Standard dosing regimens for immunocompetent patients:
- Valacyclovir 1000 mg three times daily for 7 days is highly effective and resolves zoster-associated pain and postherpetic neuralgia faster than acyclovir 3
- Valacyclovir 1.5 g twice daily for 7 days is equally safe and effective, with the advantage of improved compliance due to simpler dosing 4
- Famciclovir 500 mg three times daily for 7 days demonstrates similar efficacy to valacyclovir 3
- Acyclovir 800 mg five times daily for 7 days is effective but requires more frequent dosing 1, 2, 3
All antiviral medications are generally well-tolerated, with common side effects including nausea, headache, and gastrointestinal disturbances. 5
Timing of Treatment
Antiviral therapy is most effective when started within 72 hours after rash onset 1, 2, though observational data suggests valacyclovir may still provide benefit when started later than 72 hours 3. The key principle is to initiate treatment as soon as possible after symptoms appear 3.
Urgent Indications for Antiviral Therapy
Antiviral treatment is urgently indicated in:
- All patients over 50 years of age 2
- Herpes zoster involving the head and neck area, especially zoster ophthalmicus 2
- Severe herpes zoster on the trunk or extremities 2
- Immunosuppressed patients 2
- Patients with severe atopic dermatitis or eczema 2
Relative indications exist for patients younger than 50 years with zoster on the trunk or extremities. 2
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. 5, 6 Treatment duration may need to be prolonged beyond the standard 7 days until complete clinical resolution 6.
Pain Management
Combine appropriately dosed analgesics with a neuroactive agent (such as amitriptyline) alongside antiviral therapy to achieve painlessness. 2 This multimodal approach addresses both the acute viral infection and the neuropathic pain component.
- Narcotics may be required for adequate pain control in patients with postherpetic neuralgia 1
- Tricyclic antidepressants or anticonvulsants in low dosages help control neuropathic pain 1
- Capsaicin, lidocaine patches, and nerve blocks can be used in selected patients 1
Corticosteroid Consideration
Oral corticosteroids may provide modest benefits in reducing acute zoster pain but have no essential effect on preventing postherpetic neuralgia. 2 Their use should be considered adjunctive rather than primary therapy.
Patient Education and Precautions
Advise patients that lesions are contagious to individuals who have not had chickenpox and to avoid contact with susceptible individuals until all lesions have crusted over. 5, 6
Special Considerations
Ocular involvement (zoster ophthalmicus) can lead to serious complications and generally merits referral to an ophthalmologist. 1 Valacyclovir and acyclovir demonstrate similar efficacy for controlling ocular complications 3.
Common Pitfalls
Suboptimal treatment occurs when antiviral agents are not prescribed to high-risk patients (those over 50 years) who present beyond 72 hours of rash onset. 7 In observational studies, only 50% of high-risk patients received appropriate antiviral therapy, primarily due to delayed presentation 7. Age and severity of pain are significantly associated with persistence of pain beyond 3 months, making early aggressive treatment in these populations critical 7.