What is the recommended treatment for shingles?

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, 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 1 gram three times daily for 7-10 days is the preferred first-line option due to superior bioavailability and convenient dosing 1, 2
• Famciclovir 500 mg three times daily for 7-10 days offers equivalent efficacy with the same dosing frequency 1, 3
• Acyclovir 800 mg five times daily for 7-10 days is effective but requires more frequent dosing, which reduces compliance 1, 4

All three medications shorten viral shedding, accelerate rash healing by 1-2 days, and reduce the intensity and duration of acute pain 5. Treatment is most effective when initiated within 48 hours of rash onset, though the 72-hour window remains the maximum timeframe for optimal benefit 1, 6.

Critical Treatment Endpoint

Continue antiviral therapy until all lesions have completely scabbed—this is the key clinical endpoint, not an arbitrary 7-day duration. 1 If lesions remain active beyond 7 days, extend treatment accordingly 1. This is particularly important in immunocompromised patients who may have delayed healing 1.

When to Escalate to Intravenous Therapy

Switch to intravenous acyclovir 5-10 mg/kg every 8 hours for:

• Disseminated herpes zoster (multi-dermatomal or visceral involvement) 1
• Immunocompromised patients, especially those on active chemotherapy 1
• Complicated facial zoster with suspected CNS involvement 1
• Severe ophthalmic disease 1
• Patients who cannot tolerate oral medications 1

In immunocompromised patients with disseminated disease, consider temporarily reducing immunosuppressive medications while on IV acyclovir 1. Continue IV therapy for a minimum of 7-10 days and until clinical resolution is achieved 1.

Special Populations Requiring Aggressive Management

Immunocompromised patients (HIV, transplant recipients, cancer patients on chemotherapy) require immediate IV acyclovir due to high risk of dissemination and vision-threatening complications 1. For kidney transplant recipients with uncomplicated disease, oral acyclovir or valacyclovir is appropriate 1.

Facial or ophthalmic zoster warrants urgent treatment within 72 hours due to risk of cranial nerve complications and vision loss 1. Consider ophthalmology referral for any eye involvement 7.

Patients with renal impairment require mandatory dose adjustments to prevent acute renal failure 1. For famciclovir, adjust based on creatinine clearance (e.g., 500 mg every 8 hours for CrCl ≥60 mL/min) 1. Monitor renal function closely during IV acyclovir therapy 1.

Pain Management

Combine antivirals with appropriately dosed analgesics and consider adding a neuroactive agent like amitriptyline for acute zoster pain 6. Topical anesthetics provide minimal benefit and are not recommended as primary therapy 1.

Short-term corticosteroids (prednisone) may be used as adjunctive therapy in select cases of severe, widespread shingles to reduce acute pain, but should be avoided in immunocompromised patients due to increased risk of disseminated infection 1. Corticosteroids do not prevent postherpetic neuralgia 6.

Common Pitfalls to Avoid

• Never use topical acyclovir alone—it is substantially less effective than systemic therapy 1, 4
• Do not use acyclovir 400 mg three times daily—this dose is only appropriate for HSV, not shingles 1
• Do not stop treatment at 7 days if lesions have not scabbed—continue until complete crusting occurs 1
• Do not delay treatment beyond 72 hours when possible, though some benefit may still occur with later initiation 8
• Failing to recognize immunocompromised patients who require more aggressive IV therapy 4

Infection Control

Patients should avoid contact with susceptible individuals (pregnant women, immunocompromised persons, those without chickenpox immunity) until all lesions have crusted, as lesions are contagious 1.

Prevention

The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes 1, 9. Ideally administer before initiating immunosuppressive therapies 1.