What are the recommended treatments for managing shingles?

Management of Shingles (Herpes Zoster)

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

First-Line Antiviral Therapy

Standard Oral Treatment Options

• Valacyclovir 1000 mg three times daily for 7 days is the preferred first-line agent due to superior bioavailability and convenient dosing compared to acyclovir 2, 4
• Famciclovir 500 mg every 8 hours for 7 days is equally effective with similar three-times-daily dosing 3, 5
• Acyclovir 800 mg five times daily for 7 days remains an acceptable alternative but requires more frequent dosing 1, 6

Critical Timing Considerations

• Treatment is most effective when initiated within 48 hours of rash onset, though the 72-hour window remains the standard cutoff for optimal efficacy 1, 7
• Evidence suggests valacyclovir may retain benefit even when started beyond 72 hours, so do not withhold treatment in late presenters 4
• The key clinical endpoint is complete scabbing of all lesions, not an arbitrary 7-day duration—extend treatment if active lesions persist 1

Special Populations and Severe Disease

Immunocompromised Patients

• Intravenous acyclovir 10 mg/kg every 8 hours is mandatory for severely immunocompromised hosts (active chemotherapy, HIV with low CD4 counts, transplant recipients) due to high dissemination risk 1, 8
• Consider temporary reduction in immunosuppressive medications when feasible during treatment of disseminated disease 1
• Continue IV therapy for minimum 7-10 days and until clinical resolution is achieved 1
• Monitor renal function closely and adjust dosing for creatinine clearance 1

Disseminated or Invasive Disease

• Any multi-dermatomal involvement, visceral involvement, or suspected CNS complications requires immediate escalation to IV acyclovir 1
• Facial zoster with ophthalmic involvement or cranial nerve complications warrants consideration for IV therapy 1

HIV-Infected Patients

• For uncomplicated herpes zoster in HIV patients with CD4+ counts ≥100 cells/mm³, oral valacyclovir 500 mg twice daily is appropriate 1
• Consider long-term acyclovir prophylaxis (400 mg 2-3 times daily) in patients with recurrent episodes 1

Adjunctive Therapies

Corticosteroids: Limited Role

• Prednisone may be added to antivirals in select cases of severe, widespread disease, but provides only modest benefit in acute pain reduction with no impact on postherpetic neuralgia rates 9
• Avoid corticosteroids in immunocompromised patients due to increased dissemination risk 1
• Contraindicated in poorly controlled diabetes, severe osteoporosis, or history of steroid-induced complications 1

Topical Therapy

• Topical antiviral therapy is substantially less effective than systemic therapy and should not be used 1

Facial Zoster: Special Considerations

• Facial involvement requires particular urgency due to risk of ophthalmic complications and cranial nerve involvement 1
• Elevate the affected area to promote drainage of edema 1
• Maintain skin hydration with emollients to prevent cracking 1
• Ophthalmic zoster generally merits ophthalmology referral 6

Prevention Strategies

Vaccination

• The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior shingles episodes 1, 7
• Ideally administer before initiating immunosuppressive therapies such as JAK inhibitors 1
• Can be given after recovery from acute shingles to prevent future episodes 1

Post-Exposure Prophylaxis

• Varicella zoster immunoglobulin (or IVIG) within 96 hours of exposure for varicella-susceptible immunocompromised patients 1
• If immunoglobulin unavailable or >96 hours post-exposure, give oral acyclovir for 7 days starting 7-10 days after exposure 1

Infection Control

• Patients must avoid contact with susceptible individuals (those without prior chickenpox or vaccination) until all lesions have crusted, as lesions can transmit varicella 1, 8
• Viral shedding peaks in the first 24 hours when lesions are vesicular 1

Common Pitfalls to Avoid

• Do not stop antivirals at 7 days if lesions remain active—continue until complete scabbing 1
• Do not use the lower acyclovir dose of 400 mg TDS (appropriate only for genital herpes, not shingles) 1
• Do not rely solely on clinical diagnosis in immunocompromised patients with atypical presentations—obtain laboratory confirmation 1
• Do not add corticosteroids routinely, as they increase adverse events without preventing postherpetic neuralgia 9