Treatment Guidelines for Shingles (Herpes Zoster)
First-Line Antiviral Therapy
Oral antiviral therapy should be initiated as soon as possible, ideally within 48-72 hours of rash onset, with treatment continued until all lesions have scabbed over. 1, 2
Recommended Oral Antiviral Regimens
The following three oral antivirals are FDA-approved and equally effective first-line options for immunocompetent adults with uncomplicated herpes zoster:
- Valacyclovir 1 gram orally three times daily for 7 days 2
- Famciclovir 500 mg orally three times daily for 7 days 3
- Acyclovir 800 mg orally five times daily for 7 days 4
Valacyclovir and famciclovir offer superior bioavailability compared to acyclovir and require less frequent dosing (three times daily versus five times daily), which may improve adherence 1, 5. All three agents demonstrate similar efficacy in controlling acute symptoms and reducing zoster-associated pain 5, 6.
Treatment Duration and Timing
Treatment should continue at least until all lesions have scabbed, which is the key clinical endpoint—not an arbitrary 7-day duration. 1 If lesions remain active beyond 7 days, extend antiviral therapy until complete crusting occurs 1. While initiating treatment within 72 hours is ideal, evidence suggests valacyclovir may still provide benefit when started later than 72 hours after rash onset 5.
Severe or Complicated Disease
Intravenous acyclovir is the treatment of choice for disseminated herpes zoster, visceral involvement, or severe disease requiring hospitalization. 1, 7
For immunocompromised patients with severe disease or complications, intravenous acyclovir 5 mg/kg every 8 hours should be administered, with longer treatment duration until clinical resolution is achieved 7. Consider temporary reduction in immunosuppressive medications in these patients 1.
Special Populations
Immunocompromised Patients
- Uncomplicated herpes zoster: Oral acyclovir or valacyclovir 1
- Disseminated or invasive disease: Intravenous acyclovir with temporary reduction in immunosuppressive therapy 1
- Monitor closely for cutaneous dissemination and visceral involvement; if signs occur, switch to intravenous therapy 6
Facial/Ophthalmic Involvement
Herpes zoster ophthalmicus and facial involvement require urgent systemic antiviral therapy due to risk of cranial nerve complications 8. Valacyclovir and acyclovir demonstrate similar efficacy for controlling ocular complications 5.
Elderly Patients (≥50 years)
Systemic antiviral therapy is urgently indicated in all patients over age 50, as this population faces significantly increased risk for postherpetic neuralgia and severe complications 8. Treatment reduces duration and intensity of zoster-associated pain and provides more rapid skin lesion healing 6.
Pain Management
Appropriately dosed analgesics combined with neuroactive agents (such as amitriptyline) should be administered alongside antiviral therapy to achieve the primary treatment goal of painlessness. 8
Role of Corticosteroids
The addition of corticosteroids to antiviral therapy remains controversial. Prednisolone may provide slight benefit in reducing acute pain during the first 7-14 days but does not prevent postherpetic neuralgia 9. Corticosteroids should generally be avoided in immunocompromised patients due to increased risk of disseminated infection 1 and carry significant risks in elderly patients 1. If used, prednisone 40 mg daily tapered over three weeks can be considered as adjunctive therapy in select cases of severe, widespread disease in immunocompetent patients 1, 9.
Infection Control
Patients should be advised that lesions are contagious to individuals who have not had chickenpox and should avoid contact with susceptible individuals until all lesions have crusted. 7 This is particularly important for pregnant women, immunocompromised individuals, and those without prior varicella immunity 10.
Prevention
The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes. 1 Vaccination should ideally occur before initiating immunosuppressive therapies 1.
Common Pitfalls to Avoid
- Do not use topical antiviral therapy—it is substantially less effective than systemic therapy and is not recommended 1, 7
- Do not arbitrarily stop treatment at 7 days if lesions have not fully scabbed; continue until complete crusting occurs 1
- Do not delay treatment waiting for the 72-hour window to pass; evidence suggests benefit even with later initiation 5
- Do not rely solely on clinical diagnosis in immunocompromised patients or atypical presentations; obtain laboratory confirmation 1