Valacyclovir Treatment for Shingles
For shingles (herpes zoster), valacyclovir should be dosed at 1 gram orally three times daily for 7 days, initiated within 72 hours of rash onset, and continued until all lesions have completely scabbed. 1, 2
Standard Dosing Regimen
- The FDA-approved dose is valacyclovir 1 gram three times daily for 7 days 2
- Treatment is most effective when started within 48 hours of rash onset, though the 72-hour window remains the standard cutoff for initiating therapy 1, 3
- Continue treatment until all lesions have scabbed—this is the key clinical endpoint, not an arbitrary 7-day duration 1
- If lesions remain active beyond 7 days, extend antiviral therapy until complete scabbing occurs 1
Alternative Oral Antivirals
If valacyclovir is unavailable or not tolerated, alternative options include:
- Famciclovir 500 mg three times daily for 7 days (equally effective to valacyclovir for reducing postherpetic neuralgia duration) 4, 3
- Acyclovir 800 mg five times daily for 7 days (less convenient dosing but equally effective for acute lesion resolution, though valacyclovir shows superior reduction in zoster-associated pain duration) 3, 5
The twice-daily dosing regimen of valacyclovir 1.5 grams twice daily has been studied and shows comparable efficacy to three-times-daily dosing, potentially improving compliance 6, though this is not the FDA-approved regimen 2.
Escalation to Intravenous Therapy
Switch to IV acyclovir 10 mg/kg every 8 hours in the following situations: 1
- Disseminated herpes zoster (multi-dermatomal involvement or visceral complications)
- Immunocompromised patients with severe disease
- CNS involvement (meningitis, encephalitis)
- Severe ophthalmic zoster with vision-threatening complications
- Inability to tolerate oral medications
Continue IV therapy for at least 7-10 days and until clinical resolution is achieved 1
Special Populations
Immunocompromised Patients
- Immediate IV acyclovir is preferred for severely immunocompromised hosts (active chemotherapy, HIV with low CD4 counts, transplant recipients) due to high risk of dissemination 1
- Consider temporary reduction in immunosuppressive medications if clinically feasible 1
- Monitor closely for acyclovir resistance if lesions persist despite adequate therapy 1
Renal Impairment
- Mandatory dose adjustments based on creatinine clearance to prevent acute renal failure 1
- Monitor renal function closely during therapy, particularly with IV acyclovir 1
Facial/Ophthalmic Zoster
- Requires urgent treatment within 72 hours due to risk of vision loss and cranial nerve complications 1
- Standard oral dosing applies, but maintain low threshold for IV therapy if complications develop 1
Critical Treatment Caveats
- Topical antivirals are substantially less effective than systemic therapy and should not be used 1
- Corticosteroids may be considered as adjunctive therapy in severe cases, but should be avoided in immunocompromised patients due to dissemination risk 1
- Patients remain contagious to varicella-susceptible individuals until all lesions have crusted 1
- Valacyclovir does not eradicate latent virus but controls acute symptoms and reduces complications including postherpetic neuralgia 1