What is the treatment for shingles?

Treatment of Shingles (Herpes Zoster)

For uncomplicated shingles in immunocompetent adults, initiate oral antiviral therapy with valacyclovir 1000 mg three times daily, famciclovir 500 mg three times daily, or acyclovir 800 mg five times daily for 7-10 days, ideally within 72 hours of rash onset, and continue treatment until all lesions have completely scabbed. 1, 2

First-Line Oral Antiviral Options

The three FDA-approved oral antivirals are equally effective for treating shingles, but differ in dosing convenience:

• Valacyclovir 1000 mg three times daily offers superior bioavailability compared to acyclovir and has been shown to alleviate zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir 3

• Famciclovir 500 mg every 8 hours (three times daily) for 7 days is FDA-approved for herpes zoster and provides comparable efficacy to valacyclovir with convenient dosing 4, 5

• Acyclovir 800 mg five times daily for 7-10 days remains effective but requires more frequent dosing, which may reduce adherence 1, 2, 5

Alternative valacyclovir dosing: Valacyclovir 1.5 g twice daily has demonstrated equivalent safety and efficacy to the standard three-times-daily regimen and may enhance compliance 6

Critical Treatment Timing and Duration

• Initiate treatment within 72 hours of rash onset for optimal efficacy in reducing viral shedding, accelerating lesion healing, and preventing postherpetic neuralgia 7, 5

• Continue antiviral therapy until all lesions have completely scabbed, not just for an arbitrary 7-day period—this is the key clinical endpoint 1

• Treatment started beyond 72 hours may still provide benefit for pain reduction, though ideally therapy should begin as soon as possible 3

Escalation to Intravenous Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours in the following situations:

• Disseminated herpes zoster (multi-dermatomal involvement or visceral complications) 1
• Severely immunocompromised patients, including those on active chemotherapy 1
• Herpes zoster ophthalmicus with suspected CNS involvement 1
• Patients unable to tolerate or absorb oral medications 1

For IV therapy, continue treatment for a minimum of 7-10 days and until clinical resolution is achieved, with close monitoring of renal function 1

Special Populations

Immunocompromised Patients

• HIV-infected patients with uncomplicated shingles: Oral valacyclovir 500 mg twice daily for 7 days or higher doses (up to 800 mg 5-6 times daily) may be needed 1

• Severely immunocompromised hosts (transplant recipients, active chemotherapy): Intravenous acyclovir 10 mg/kg every 8 hours with temporary reduction in immunosuppressive medications if feasible 1

• Kidney transplant recipients with uncomplicated disease: Oral acyclovir or valacyclovir with dose adjustment for renal function 1

Pregnant Women

• Varicella zoster immunoglobulin (VZIG) within 96 hours of exposure is recommended for varicella-susceptible pregnant women exposed to active VZV infection 2

• If VZIG is unavailable or >96 hours have passed, consider a 7-day course of oral acyclovir beginning 7-10 days after exposure 1

Renal Dosing Adjustments

Reduce antiviral doses based on creatinine clearance to prevent acute renal failure, particularly in elderly patients and those with underlying renal disease 4:

• Monitor renal function closely during IV acyclovir therapy 1
• Assess for thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in immunocompromised patients receiving high-dose therapy 1

Adjunctive Corticosteroid Therapy

• Prednisone may be considered as adjunctive therapy in select cases of severe, widespread shingles in immunocompetent patients, though this carries significant risks in elderly patients 1

• Avoid corticosteroids in immunocompromised patients due to increased risk of disseminated infection 1

Critical Pitfalls to Avoid

• Never use topical acyclovir—it is substantially less effective than systemic therapy and is not recommended 1, 2

• Do not stop treatment at 7 days if lesions remain active—continue until complete scabbing occurs 1

• Do not delay treatment waiting for laboratory confirmation in typical presentations—clinical diagnosis is sufficient in immunocompetent patients 1

• Monitor for acyclovir resistance if lesions persist despite adequate treatment, particularly in HIV-infected patients 1

Prevention

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

Infection Control

• Patients should avoid contact with susceptible individuals (those who have not had chickenpox or vaccination) until all lesions have crusted, as lesions contain infectious viral particles 1