What are the treatment options for Herpes Zoster (shingles)?

From the Guidelines

Shingles treatment should begin with antiviral medications like acyclovir or famciclovir, as they have been shown to accelerate the rate of cutaneous healing and reduce the severity of acute pain when administered within 72 hours of rash onset. According to the study by 1, two nucleoside analogs, acyclovir and famciclovir, have been approved by FDA for treating HZ. The study found that if administered within 72 hours of rash onset, acyclovir has accelerated the rate of cutaneous healing and reduced the severity of acute pain in adults who have HZ. Some key points to consider when treating shingles include:

• Starting antiviral medications within 72 hours of rash onset for optimal efficacy
• Using medications like acyclovir or famciclovir, which have similar efficacy in treating HZ
• Managing pain with medications like acetaminophen, NSAIDs, gabapentin, or pregabalin, depending on the severity of pain
• Keeping the rash clean and covered to prevent spreading the virus to others
• Seeking immediate medical attention if experiencing severe pain, widespread rash, facial or eye involvement, or having a weakened immune system.

From the FDA Drug Label

1 INDICATIONS AND USAGE

1.1 Adult Patients ... Herpes Zoster VALTREX is indicated for the treatment of herpes zoster (shingles) in immunocompetent adults.

• Valacyclovir (PO) is indicated for the treatment of herpes zoster (shingles) in immunocompetent adults 2.
• Acyclovir (PO) is indicated for the acute treatment of herpes zoster (shingles) 3.
• Famciclovir (PO) is indicated for the treatment of herpes zoster (shingles) in immunocompetent adult patients 4.

From the Research

Shingles Treatment Overview

• Shingles, also known as herpes zoster, is diagnosed clinically by recognition of the distinctive, painful vesicular rash appearing in a unilateral, dermatomal distribution 5.
• Treatment with acyclovir, famciclovir, or valacyclovir decreases the duration of the rash 5, 6.
• Adjunct medications, including opioid analgesics, tricyclic antidepressants, or corticosteroids, may relieve the pain associated with acute herpes zoster 5.

Antiviral Therapy

• Oral antiviral agents, such as acyclovir, valacyclovir, and famciclovir, are the most important therapeutic keystone in the treatment of herpes zoster 6.
• Meta-analysis of published data has shown that oral acyclovir significantly reduces various herpes zoster-related symptoms as well as the duration, intensity, and prevalence of zoster-associated pain (ZAP) 6.
• The newer agents famciclovir and valacyclovir exhibit a better oral bioavailability than acyclovir and have demonstrated similar efficacy to acyclovir with ZAP 6.

Prevention of Postherpetic Neuralgia

• There is conflicting evidence that antiviral therapy during the acute phase prevents postherpetic neuralgia 5.
• The combination of gabapentin and valacyclovir administered acutely in patients with herpes zoster reduces the incidence of postherpetic neuralgia 7.
• Evidence supports treating postherpetic neuralgia with tricyclic antidepressants, gabapentin, pregabalin, long-acting opioids, or tramadol; moderate evidence supports the use of capsaicin cream or a lidocaine patch as a second-line agent 5.

Immunization

• Immunization to prevent herpes zoster and postherpetic neuralgia is recommended for most adults 60 years and older 5.