What is the treatment and management for shingles (herpes zoster)?

Treatment and Management of Shingles (Herpes Zoster)

First-Line Antiviral Therapy

For uncomplicated shingles in immunocompetent adults, initiate oral antiviral therapy immediately—preferably within 72 hours of rash onset—with valacyclovir 1000 mg three times daily or famciclovir 500 mg every 8 hours for 7 days, continuing until all lesions have completely scabbed. 1, 2, 3

Oral Antiviral Options (in order of preference based on dosing convenience):

• Valacyclovir 1000 mg three times daily for 7 days is the preferred first-line agent due to superior bioavailability and less frequent dosing compared to acyclovir, which improves adherence 1, 3, 4

• Famciclovir 500 mg every 8 hours for 7 days offers equivalent efficacy to valacyclovir with similar dosing convenience 1, 2, 4

• Acyclovir 800 mg five times daily for 7-10 days is effective but requires more frequent dosing, which may reduce adherence 1, 5, 6

Critical Timing Considerations:

• Treatment is most effective when initiated within 48 hours of rash onset, but the 72-hour window remains the standard cutoff for optimal efficacy 1

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

• Treatment may still provide benefit when initiated beyond 72 hours, particularly for reducing pain duration, though this is not FDA-approved 4

Special Populations Requiring Intravenous Therapy

Immunocompromised patients with disseminated or invasive herpes zoster require immediate intravenous acyclovir 10 mg/kg every 8 hours, with temporary reduction in immunosuppressive medications when feasible. 1, 7

Indications for IV Acyclovir:

• Disseminated herpes zoster (multi-dermatomal involvement or visceral involvement) 1, 8

• Severely immunocompromised hosts (active chemotherapy, HIV with low CD4 counts, solid organ transplant recipients) 1, 7

• Complicated facial zoster with suspected CNS involvement or severe ophthalmic disease 1

• Herpes zoster ophthalmicus with ocular complications 1

IV Therapy Duration and Monitoring:

• Continue IV acyclovir for a minimum of 7-10 days and until clinical resolution is attained 1

• Monitor renal function closely during IV therapy with dose adjustments for renal impairment 1

• Assess for thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in immunocompromised patients receiving high-dose therapy 1

Dose Adjustments for Renal Impairment

Mandatory dose reductions are required for patients with renal impairment to prevent acute renal failure. 1, 2

Famciclovir Dosing by Creatinine Clearance (for herpes zoster):

• CrCl ≥60 mL/min: 500 mg every 8 hours 2
• CrCl 40-59 mL/min: 500 mg every 12 hours 2
• CrCl 20-39 mL/min: 500 mg every 24 hours 2
• CrCl <20 mL/min: 250 mg every 24 hours 2
• Hemodialysis: 250 mg following each dialysis 2

Adjunctive Corticosteroid Therapy

Corticosteroids may provide modest benefit for acute pain reduction but do not prevent postherpetic neuralgia and carry significant risks, particularly in elderly patients. 1, 9

• Prednisone (starting at 40 mg daily, tapered over 3 weeks) can be considered as adjunctive therapy in select cases of severe, widespread shingles 1, 9

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

• Contraindications include poorly controlled diabetes, history of steroid-induced psychosis, severe osteoporosis, or prior severe steroid toxicity 1

• The addition of prednisolone to acyclovir confers only slight benefits over standard acyclovir therapy alone and does not reduce postherpetic neuralgia 9

Special Considerations for Facial and Ophthalmic Involvement

Facial herpes zoster requires urgent antiviral therapy due to risk of ophthalmic and cranial nerve complications. 1

• Initiate oral valacyclovir 1 gram three times daily or famciclovir 500 mg three times daily within 72 hours of rash onset 1

• Elevation of the affected area promotes drainage of edema and inflammatory substances 1

• Keep skin well hydrated with emollients to avoid dryness and cracking 1

• Consider ophthalmology referral for any suspected ocular involvement 6

Infection Control Measures

Patients with active shingles must avoid contact with susceptible individuals (those who have not had chickenpox or vaccination) until all lesions have crusted, as the lesions are contagious. 1

• Viral shedding peaks in the first 24 hours after lesion onset when most lesions are vesicular 1

• Varicella zoster immunoglobulin (or IVIG) should be administered within 96 hours of exposure to varicella-susceptible pregnant women, immunocompromised patients, or other high-risk individuals 1

Prevention: Vaccination

The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes. 1

• Vaccination should ideally occur before initiating immunosuppressive therapies 1

• The recombinant vaccine can be considered after recovery from acute shingles to prevent future episodes 1

• Live-attenuated vaccines (Zostavax) are contraindicated in immunocompromised patients 1

Important Caveats

• Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 1, 7

• Antiviral medications do not eradicate latent virus but help control symptoms and reduce complications 1

• For acyclovir-resistant cases (rare), foscarnet 40 mg/kg IV every 8 hours is the treatment of choice 1

• Laboratory confirmation (PCR, immunofluorescence, or culture) is needed for immunocompromised patients with atypical presentations 1, 10