Treatment of Shingles (Herpes Zoster)
For uncomplicated shingles, start oral valacyclovir 1 gram three times daily or famciclovir 500 mg three times daily for 7-10 days, continuing until all lesions have completely scabbed. 1, 2
First-Line Antiviral Therapy
Initiate treatment as soon as possible—ideally within 48-72 hours of rash onset—though treatment beyond 72 hours still provides benefit. 1, 3
Oral Antiviral Options (Choose One):
Valacyclovir 1 gram three times daily for 7-10 days—preferred due to convenient dosing and superior bioavailability 1, 2
Famciclovir 500 mg three times daily for 7-10 days—equally effective with convenient dosing 1, 4
Acyclovir 800 mg five times daily for 7-10 days—effective but requires more frequent dosing, which may reduce compliance 1, 3
Critical endpoint: Continue treatment until ALL lesions have scabbed, not just for an arbitrary 7-day period. 1, 3 Treatment may need extension beyond 7 days if lesions remain active. 3
When to Escalate to Intravenous Therapy
Switch to IV acyclovir 5 mg/kg every 8 hours for: 1, 5, 3
- Disseminated herpes zoster (multi-dermatomal or visceral involvement) 1
- Immunocompromised patients with severe disease 5, 3
- Facial zoster with suspected CNS involvement or severe ophthalmic disease 1
- Any patient unable to tolerate oral medications 5
In immunocompromised patients with disseminated disease, temporarily reduce immunosuppressive medications while on IV acyclovir. 1, 3
Special Populations and Situations
Facial/Ophthalmic Involvement:
- Requires urgent antiviral therapy due to risk of cranial nerve and vision complications 1
- Elevate the affected area to promote drainage 1
- Keep skin well-hydrated with emollients 1
- Consider ophthalmology referral for any eye involvement 6
Immunocompromised Patients:
- Require more aggressive management with consideration for IV therapy 5, 3
- May need longer treatment duration until complete clinical resolution 5
- Monitor closely for disseminated disease 1
Kidney Transplant Recipients:
- Oral acyclovir or valacyclovir for uncomplicated cases 1
- IV acyclovir with temporary immunosuppression reduction for disseminated disease 1
Adjunctive Therapies
Corticosteroids:
- Prednisone may be considered as adjunctive therapy in select cases of severe, widespread shingles 1
- Avoid in immunocompromised patients due to increased risk of disseminated infection 1
- Avoid in patients with poorly controlled diabetes, history of steroid-induced psychosis, severe osteoporosis, or prior severe steroid toxicity 1
Pain Management:
- Acute pain may require analgesics ranging from NSAIDs to narcotics 6
- For postherpetic neuralgia: consider tricyclic antidepressants, anticonvulsants, capsaicin, or lidocaine patches 6
Critical Pitfalls to Avoid
- Never use topical acyclovir—it is substantially less effective than oral therapy 1, 3
- Do not stop treatment at 7 days if lesions have not completely scabbed 1, 3
- Do not delay treatment waiting for the 72-hour window to pass—later treatment still provides benefit 1
- Do not underdose or use inadequate treatment duration, which increases complication risk 3
Infection Control
Patients must avoid contact with susceptible individuals (those who haven't had chickenpox or vaccination) until all lesions have crusted. 1, 5 Lesion fluid contains infectious viral particles. 5
Prevention and Follow-Up
- Recommend Shingrix (recombinant zoster vaccine) for all adults ≥50 years, regardless of prior shingles episodes 1
- Ideally vaccinate before initiating immunosuppressive therapies 1
- Monitor renal function during IV acyclovir therapy with dose adjustments for renal impairment 1
- Assess for complete healing of all lesions 1, 3