What is the recommended treatment for shingles?

Treatment of Shingles (Herpes Zoster)

For 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 7-10 days, starting within 72 hours of rash onset and continuing until all lesions have completely crusted. 1, 2, 3, 4

First-Line Oral Antiviral Options

All three FDA-approved antivirals are equally effective for treating shingles, but differ in dosing convenience 5, 6:

• Valacyclovir 1 gram three times daily for 7 days - preferred for better compliance due to less frequent dosing 4, 7
• Famciclovir 500 mg three times daily for 7 days - equally effective with convenient three-times-daily dosing 8, 5, 6
• Acyclovir 800 mg five times daily for 7-10 days - effective but requires more frequent dosing which may reduce adherence 3, 5

Critical Timing and Duration

• Start treatment within 72 hours of rash onset for maximum effectiveness, though treatment is most beneficial when initiated within 48 hours 2, 9, 6
• Continue therapy until all lesions have completely scabbed, not just for an arbitrary 7-day period - this is the key clinical endpoint 1, 2, 3
• Treatment may need extension beyond 7 days if lesions remain active 2, 3

Special Populations Requiring Intravenous Therapy

Escalate to IV acyclovir 5 mg/kg every 8 hours for: 1, 2, 3

• Immunocompromised patients with severe disease or complications
• Disseminated herpes zoster (multi-dermatomal or visceral involvement)
• Complicated facial zoster with suspected CNS involvement or severe ophthalmic disease
• Any patient requiring hospitalization for shingles complications

For immunocompromised patients with disseminated disease, consider temporary reduction in immunosuppressive medications and continue IV therapy until clinical resolution 1, 2

High-Risk Situations Requiring Urgent Treatment

Initiate antiviral therapy immediately (even beyond 72 hours) for: 6

• Patients over 50 years of age
• Facial or head/neck involvement, especially zoster ophthalmicus
• Immunosuppressed patients at any age
• Severe disease on trunk or extremities
• Patients with severe atopic dermatitis or eczema

Adjunctive Pain Management

Antivirals alone address viral replication but not acute pain 6:

• Combine appropriately dosed analgesics with neuroactive agents (such as amitriptyline) during acute phase 6
• Corticosteroids (prednisone) may provide modest benefit for acute pain reduction but should be used selectively 2, 9
• Avoid corticosteroids in immunocompromised patients due to risk of disseminated infection 2

Critical Pitfalls to Avoid

• Never use topical acyclovir - it is substantially less effective than oral therapy and is not recommended 2, 3
• Do not rely on arbitrary 7-day treatment duration - continue until all lesions have crusted 2, 3
• Do not underdose or use inadequate duration - this leads to treatment failure and increased complication risk 3
• Do not delay treatment in high-risk patients even if presenting beyond 72 hours 6

Infection Control

• Lesions are contagious to individuals who have not had chickenpox 1, 2
• Patients must avoid contact with susceptible individuals (pregnant women, immunocompromised persons, infants) until all lesions have crusted 1, 2
• Viral shedding peaks in the first 24 hours after lesion onset 2

Monitoring and Follow-Up

• Monitor for complete healing of lesions as the primary endpoint 1, 3
• For IV acyclovir, monitor renal function closely with dose adjustments for renal impairment 2
• Assess for thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in immunocompromised patients receiving high-dose therapy 2
• Common side effects of oral antivirals include nausea, headache, and gastrointestinal disturbances 1

Prevention

• The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior shingles episodes 2
• Vaccination should ideally occur before initiating immunosuppressive therapies 2