What is the recommended management for shingles?

Management of Shingles (Herpes Zoster)

First-Line Antiviral Therapy

For uncomplicated herpes zoster, initiate oral valacyclovir 1 gram three times daily for 7 days, continuing treatment until all lesions have completely scabbed. 1, 2

Antiviral Options and Dosing

• Valacyclovir 1 gram orally three times daily for 7 days is the preferred first-line agent due to superior bioavailability and convenient dosing compared to acyclovir 2, 3
• Famciclovir 500 mg orally three times daily for 7 days is equally effective to valacyclovir and represents an appropriate alternative 1, 3
• Acyclovir 800 mg orally five times daily for 7 days remains effective but requires more frequent dosing, which may reduce adherence 2, 4

Critical Timing Considerations

• Treatment is most effective when initiated within 48-72 hours of rash onset, though benefit may still occur when started later 1, 2, 5
• The 72-hour window represents the maximum timeframe for optimal efficacy, but treatment should not be withheld if presenting beyond this window 1, 3
• Continue antiviral therapy until all lesions have scabbed—this is the key clinical endpoint, not an arbitrary 7-day duration 1

Escalation to Intravenous Therapy

Intravenous acyclovir 5-10 mg/kg every 8 hours is required for disseminated or invasive herpes zoster, particularly in immunocompromised patients. 1, 6

Indications for IV Acyclovir

• Disseminated herpes zoster (multi-dermatomal involvement or visceral involvement) 1
• Severe immunocompromised state with complicated disease 1, 6
• Suspected CNS involvement or severe ophthalmic disease 1
• Failure to respond to oral therapy or inability to tolerate oral medications 6

Special Monitoring with IV Therapy

• Monitor renal function closely during IV acyclovir therapy with dose adjustments for renal impairment 1
• Assess for thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in immunocompromised patients receiving high-dose therapy 1

Immunocompromised Patients

• For uncomplicated herpes zoster in kidney transplant recipients, use oral acyclovir or valacyclovir at standard doses 1
• For disseminated or invasive disease, use IV acyclovir with temporary reduction in immunosuppressive medications 1
• Longer duration of therapy may be needed until clinical resolution is attained 6

Adjunctive Corticosteroid Therapy

Corticosteroids provide only modest benefits in reducing acute pain and should not be routinely used, as they do not prevent postherpetic neuralgia. 7

Limited Role of Prednisone

• Prednisone may be considered as adjunctive therapy in select cases of severe, widespread shingles, but carries significant risks particularly in elderly patients 1
• A 21-day tapering course starting at 40 mg daily showed slightly greater pain reduction during the acute phase but no difference in postherpetic neuralgia rates 7
• 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

Special Populations and Situations

Facial and Ophthalmic Herpes Zoster

• Facial zoster requires urgent treatment due to risk of ophthalmic and cranial nerve complications 1
• Initiate oral valacyclovir 1 gram three times daily or famciclovir 500 mg three times daily immediately 1
• Consider IV acyclovir for complicated facial zoster with suspected CNS involvement 1
• Elevation of the affected area promotes drainage of edema and inflammatory substances 1
• Keep skin well hydrated with emollients to avoid dryness and cracking 1

Pediatric Patients

• For chickenpox in immunocompetent children aged 2 to <18 years: valacyclovir 20 mg/kg three times daily for 5 days (maximum 1 gram per dose) 2
• For cold sores in children ≥12 years: valacyclovir 2 grams twice daily for 1 day 2

Infection Control and Prevention

Isolation Precautions

• Patients with shingles must avoid contact with susceptible individuals (those who have never had chickenpox or vaccination) until all lesions have crusted 1, 6
• Lesions are contagious to varicella-susceptible individuals throughout the vesicular phase 6
• Viral shedding peaks in the first 24 hours after lesion onset when most lesions are vesicular 1

Post-Exposure Prophylaxis

• Administer varicella zoster immunoglobulin (or IVIG) within 96 hours of exposure for varicella-susceptible patients exposed to active varicella zoster infection 8, 1
• If immunoglobulin is unavailable or >96 hours have passed, give oral acyclovir for 7 days beginning 7-10 days after exposure 1

Vaccination

• The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes 1, 9
• Vaccination should ideally occur before initiating immunosuppressive therapies 1
• The vaccine can be considered after recovery from acute herpes zoster to prevent future episodes 1

Common Pitfalls to Avoid

• Do not rely on topical antiviral therapy—it is substantially less effective than systemic therapy and is not recommended 1
• Do not discontinue antiviral therapy at 7 days if lesions have not completely scabbed; continue until full crusting occurs 1
• Do not delay treatment waiting for laboratory confirmation in typical presentations; clinical diagnosis is sufficient in immunocompetent patients 1
• Do not withhold treatment beyond 72 hours—while earlier is better, later treatment may still provide benefit 3

Adverse Effects and Tolerability

• Antiviral medications are generally well-tolerated with common side effects including nausea, headache, and gastrointestinal disturbances 6, 3
• Valacyclovir and famciclovir have similar adverse event profiles to acyclovir 3
• VALTREX may be given without regard to meals 2