What is the recommended treatment for a shingles outbreak?

Treatment for Shingles Outbreak

For immunocompetent adults with shingles, initiate oral antiviral therapy with valacyclovir 1 gram three times daily, famciclovir 500 mg three times daily, or acyclovir 800 mg five times daily for 7 days, starting ideally within 72 hours of rash onset and continuing until all lesions have completely scabbed. 1, 2, 3

First-Line Oral Antiviral Options

The three FDA-approved oral antivirals are equally effective for treating shingles, with choice based primarily on dosing convenience:

• Valacyclovir 1 gram three times daily for 7 days offers superior bioavailability compared to acyclovir and convenient three-times-daily dosing 3, 4
• Famciclovir 500 mg every 8 hours for 7 days provides equivalent efficacy with three-times-daily dosing 2, 5
• Acyclovir 800 mg five times daily for 7 days remains effective but requires more frequent dosing, which may reduce adherence 6, 5

Critical Timing and Duration

• Initiate treatment within 72 hours of rash onset for maximum benefit in reducing acute pain and preventing postherpetic neuralgia 1, 6, 7
• Continue therapy until all lesions have completely scabbed, not just for an arbitrary 7-day period—this is the key clinical endpoint 1
• Treatment initiated beyond 72 hours may still provide benefit for pain reduction, though earlier treatment is strongly preferred 4

Escalation to Intravenous Therapy

Switch to intravenous acyclovir 5-10 mg/kg every 8 hours for:

• Disseminated herpes zoster (multi-dermatomal involvement or visceral spread) 1
• Immunocompromised patients with severe disease 1
• Facial zoster with suspected CNS involvement or severe ophthalmic complications 1
• Consider temporary reduction in immunosuppressive medications in transplant recipients or other immunocompromised patients with disseminated disease 1

Special Populations

HIV-Infected Patients

• Use famciclovir 500 mg twice daily for 7 days or valacyclovir 500 mg twice daily for recurrent episodes 2
• Higher doses may be needed for severe immunosuppression 8

Renal Impairment

• Valacyclovir: Reduce to 1 gram every 12 hours for CrCl 30-49 mL/min; 1 gram every 24 hours for CrCl 10-29 mL/min 3
• Famciclovir: Reduce to 500 mg every 12 hours for CrCl 40-59 mL/min; 500 mg every 24 hours for CrCl 20-39 mL/min 2
• Monitor renal function closely during IV acyclovir therapy with dose adjustments as needed 1

Facial/Ophthalmic Involvement

• Requires urgent treatment due to risk of vision loss and cranial nerve complications 1
• Consider ophthalmology consultation for any suspected ocular involvement 6
• Elevation of affected area and skin hydration with emollients are recommended adjunctive measures 1

Adjunctive Corticosteroid Therapy

• Prednisone may be considered as adjunctive therapy in select cases of severe, widespread shingles in immunocompetent patients 1
• Avoid corticosteroids in immunocompromised patients due to increased risk of disseminated infection 1
• Contraindicated in patients with poorly controlled diabetes, severe osteoporosis, or history of steroid-induced complications 1

Key Caveats

• Topical antiviral therapy is not recommended—it is substantially less effective than systemic treatment 1
• Antivirals do not eradicate latent virus but control symptoms and reduce complications 1
• Patients remain contagious until all lesions have crusted—avoid contact with susceptible individuals (pregnant women, immunocompromised persons, those without prior varicella immunity) 1
• Valacyclovir at very high doses (8 g/day) has been associated with thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in immunocompromised patients, though standard doses appear safe 8, 1

Prevention for Future Episodes

• Recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior shingles episodes 1, 7
• Vaccination should ideally occur before initiating immunosuppressive therapies 1