Treatment of Herpes Zoster
For uncomplicated herpes zoster, initiate oral valacyclovir 1 gram three times daily for 7 days, starting within 72 hours of rash onset when possible. 1
First-Line Antiviral Therapy for Uncomplicated Disease
Valacyclovir 1 gram orally three times daily for 7 days is the preferred first-line treatment for uncomplicated herpes zoster in immunocompetent patients 1
Alternative oral regimens include:
Treatment must be initiated within 72 hours of rash onset to maximize effectiveness in reducing severity, duration of eruption, and acute pain intensity 1, 3
Delayed initiation beyond 72 hours significantly reduces treatment effectiveness 1
Valacyclovir and famciclovir offer superior bioavailability and more convenient dosing schedules compared to acyclovir's five-times-daily regimen, potentially improving adherence 1, 2
Treatment Duration and Endpoints
Continue antiviral therapy until all lesions have scabbed, not based on arbitrary calendar days 4
The standard minimum duration is 7-10 days, but treatment should be extended if new lesions continue to form or healing remains incomplete 1, 4
Complete scabbing of all lesions is the key clinical endpoint that determines when to stop therapy 4
Severe or Disseminated Disease
For disseminated, multi-dermatomal, ophthalmic, visceral, or complicated herpes zoster, use intravenous acyclovir 5-10 mg/kg every 8 hours 1
Continue IV therapy until clinical improvement occurs, then switch to oral therapy to complete the treatment course 1
Treatment must continue for a minimum of 7-10 days and until clinical resolution is attained 1
Monitor renal function closely during IV acyclovir therapy with dose adjustments for renal impairment 4
Management in Immunocompromised Patients
All immunocompromised patients with herpes zoster require antiviral treatment regardless of timing or duration since rash onset 1
Consider temporarily discontinuing or reducing immunosuppressive therapy in severe cases of disseminated VZV infection 1, 4
Immunosuppression may be restarted after the patient has commenced anti-VZV therapy and skin vesicles have resolved 1
Monitor closely for dissemination and visceral complications throughout treatment 1
Consider longer treatment duration if healing is delayed 1
Special Situations
Ramsay Hunt Syndrome (Herpes Zoster Oticus)
Initiate valacyclovir 1 gram orally three times daily for 7 days combined with systemic corticosteroids as soon as possible, ideally within 72 hours 5
Systemic corticosteroids should be added given facial nerve involvement to potentially improve nerve recovery outcomes 5
Do not delay treatment waiting for laboratory confirmation—diagnosis is clinical and treatment must begin immediately 5
HIV-Infected Patients
- For recurrent orolabial or genital herpes in HIV-infected patients, use famciclovir 500 mg twice daily for 7 days 2
Acyclovir-Resistant Cases
For suspected acyclovir-resistant herpes zoster, use foscarnet 40 mg/kg IV every 8 hours 1
Acyclovir-resistant isolates are routinely resistant to ganciclovir as well 1
Renal Dose Adjustments
For patients with creatinine clearance 40-59 mL/min: famciclovir 500 mg every 12 hours 2
For creatinine clearance 20-39 mL/min: famciclovir 500 mg every 24 hours 2
For creatinine clearance <20 mL/min: famciclovir 250 mg every 24 hours 2
For hemodialysis patients: famciclovir 250 mg following each dialysis 2
Critical Pitfalls to Avoid
Never use topical antiviral therapy as it is substantially less effective than systemic therapy 4, 5
Do not wait for laboratory confirmation to initiate treatment in typical presentations 5
Do not confuse herpes zoster with other conditions—the presence of dermatomal vesicular rash with pain is diagnostic 5
Antiviral medications do not eradicate latent virus but control symptoms and reduce complications 4
Infection Control
Patients with shingles must avoid contact with susceptible individuals (those who have not had chickenpox) until all lesions have crusted 4
Viral shedding peaks in the first 24 hours after lesion onset when most lesions are vesicular 4