What is the recommended management for shingles?

Management of Shingles (Herpes Zoster)

For uncomplicated shingles, initiate oral antiviral therapy with valacyclovir 1 gram three times daily or famciclovir 500 mg three times daily for 7 days, starting ideally within 48-72 hours of rash onset and continuing until all lesions have completely scabbed. 1, 2, 3

First-Line Antiviral Treatment

Oral antiviral agents are the cornerstone of shingles management:

• Valacyclovir 1 gram orally three times daily for 7 days is the preferred first-line option due to superior bioavailability and convenient dosing 1, 2, 4
• Famciclovir 500 mg orally three times daily for 7 days offers equivalent efficacy with less frequent dosing than acyclovir 1, 3, 4
• Acyclovir 800 mg orally five times daily for 7 days remains effective but requires more frequent dosing, which may reduce adherence 1, 5, 6

Critical timing considerations:

• Treatment is most effective when initiated within 48 hours of rash onset 1, 2
• The 72-hour window represents the maximum timeframe for optimal efficacy, though some benefit may still occur beyond this point 1, 6, 7
• Continue treatment until all lesions have completely scabbed, not just for an arbitrary 7-day period—this is the key clinical endpoint 1

Escalation to Intravenous Therapy

Intravenous acyclovir is required for severe or complicated cases:

• Disseminated herpes zoster (multi-dermatomal involvement or visceral disease) requires IV acyclovir 5-10 mg/kg every 8 hours 1
• Immunocompromised patients with severe disease should receive IV acyclovir with consideration for temporary reduction in immunosuppressive medications 1
• Herpes zoster ophthalmicus with suspected CNS involvement or severe ophthalmic complications warrants IV therapy 1
• Monitor renal function closely during IV therapy and adjust doses for renal impairment 1, 5

Pain Management

Adequate analgesia is essential and should be initiated concurrently with antiviral therapy:

• Appropriately dosed analgesics combined with neuroactive agents (such as amitriptyline) are very helpful when given together with antiviral therapy 7
• For acute zoster pain, consider standard analgesics escalating to opioids if needed 6, 8
• Early initiation of gabapentin or amitriptyline after onset may reduce risk of developing postherpetic neuralgia in high-risk patients 8

Adjunctive Corticosteroid Therapy

The role of corticosteroids remains limited and should be used selectively:

• Prednisone may provide modest benefits in reducing acute pain and accelerating healing during the acute phase 1, 9
• However, corticosteroids do not reduce the incidence of postherpetic neuralgia, which is the most important long-term outcome 9
• Avoid corticosteroids in immunocompromised patients due to increased risk of disseminated infection 1
• Contraindications include poorly controlled diabetes, history of steroid-induced psychosis, severe osteoporosis, or prior severe steroid toxicity 1

Given the lack of benefit for postherpetic neuralgia prevention and potential adverse effects, routine corticosteroid use is not recommended. 9

Special Populations and Situations

Facial and ophthalmic involvement:

• Facial zoster requires urgent treatment due to risk of cranial nerve complications 1
• Herpes zoster ophthalmicus warrants ophthalmology referral and aggressive antiviral therapy 6, 4
• Keep affected skin well hydrated with emollients to prevent dryness and cracking 1

Immunocompromised patients:

• Kidney transplant recipients with uncomplicated disease can receive oral antivirals 1
• High-dose IV acyclovir remains the treatment of choice for severely immunocompromised hosts with disseminated disease 1
• Consider temporary reduction in immunosuppressive medications for disseminated or invasive disease 1

Infection Control

Patients with active shingles are contagious to varicella-susceptible individuals:

• Avoid contact with pregnant women, immunocompromised individuals, and those without prior varicella immunity until all lesions have crusted 1
• Lesions remain contagious until completely scabbed over 1

Prevention

Vaccination is critical for preventing future episodes:

• 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
• The vaccine can be considered after recovery from an acute episode to prevent future recurrences 1

Important Caveats

• Topical antiviral therapy is substantially less effective than systemic therapy and should not be used 1
• Treatment beyond 72 hours may still provide benefit, particularly for pain reduction, so do not withhold antivirals in late presenters 4
• Extending treatment beyond 7 days is appropriate if lesions remain active and have not fully scabbed 1
• Antiviral medications control symptoms and reduce complications but do not eradicate latent virus 1