Treatment of Shingles (Herpes Zoster)
Start oral antiviral therapy within 72 hours of rash onset with valacyclovir, famciclovir, or acyclovir for 7 days to accelerate healing and reduce pain. 1, 2
First-Line Antiviral Treatment Options
The CDC recommends the following oral antiviral regimens for immunocompetent adults with shingles:
- Valacyclovir 1000 mg three times daily for 7 days - This is highly effective and offers convenient dosing 1
- Famciclovir 500 mg three times daily for 7 days - FDA-approved for herpes zoster with comparable efficacy 3
- Acyclovir 800 mg five times daily for 7-10 days - Effective but requires more frequent dosing which may reduce compliance 1, 4
Initiate treatment within 72 hours of rash onset for maximum benefit - antiviral therapy is most effective when started early in the disease course 4, 2
Immunocompromised Patients Require Different Management
- Intravenous acyclovir 5-10 mg/kg every 8 hours is recommended for severe cases, disseminated disease, or complications in immunocompromised patients 1, 5
- Treatment duration may need to be extended until complete clinical resolution is achieved 5
- HIV-infected patients and those on immunosuppressive therapy require more aggressive monitoring and potentially longer treatment courses 6, 1
Pain Management Considerations
- Acute pain during the rash phase typically improves with antiviral therapy alone 4, 2
- For severe acute pain, consider adding analgesics including NSAIDs or short-term opioids if needed 4, 2
- Tricyclic antidepressants (such as amitriptyline) or anticonvulsants (gabapentin, pregabalin) can be used for neuropathic pain control 4, 2
- Topical lidocaine patches or capsaicin may provide additional relief in selected patients 4, 2
Role of Corticosteroids (Limited Benefit)
- Adding oral corticosteroids (such as prednisolone 40 mg daily, tapered over 3 weeks) to antiviral therapy provides only modest benefits in reducing acute pain and does not prevent postherpetic neuralgia 7
- The slight improvement in acute pain must be weighed against increased adverse events with steroid use 7
- Corticosteroids are not routinely recommended for standard shingles treatment 7
Critical Pitfalls to Avoid
- Never use topical acyclovir - it is substantially less effective than oral therapy and should not be used 1
- Do not delay treatment - waiting beyond 72 hours significantly reduces antiviral efficacy 4, 2
- Avoid inadequate dosing or shortened treatment duration - this leads to treatment failure and increased complication risk 1
- Do not miss ophthalmic involvement - herpes zoster ophthalmicus requires urgent ophthalmology referral to prevent vision loss 4
- Recognize immunocompromised patients early - they require IV therapy for severe disease and cannot be managed with standard oral regimens 1, 5
Special Clinical Situations
- Ophthalmic zoster (involvement of the trigeminal ganglion affecting the eye) requires immediate ophthalmology consultation and aggressive antiviral therapy 4, 8
- Disseminated herpes zoster (lesions beyond the primary dermatome) indicates possible immunocompromise and requires IV acyclovir 8
- Pregnancy: Shingles typically has a mild course, but treatment decisions should balance maternal benefit against fetal risk 8
Follow-Up and Monitoring
- Monitor for complete resolution of lesions - extend treatment if healing is incomplete after the initial 7-day course 1
- Patients should avoid contact with individuals who have not had chickenpox until all lesions are crusted over 5
- Watch for development of postherpetic neuralgia (pain persisting >90 days after rash onset), which occurs in approximately 20% of patients and requires different management strategies 2