What is the treatment for shingles?

Treatment for Shingles (Herpes Zoster)

Start oral antiviral therapy with famciclovir 500 mg three times daily, valacyclovir 1000 mg three times daily, or acyclovir 800 mg five times daily for 7 days, initiated within 72 hours of rash onset for maximum benefit. 1, 2

First-Line Antiviral Options

All three oral antivirals are FDA-approved and equally effective for shingles treatment, but differ in dosing convenience 1, 2, 3:

• Famciclovir 500 mg orally every 8 hours (three times daily) for 7 days 1
• Valacyclovir 1000 mg orally three times daily for 7 days 2, 4
• Acyclovir 800 mg orally five times daily for 7 days 2, 3

Famciclovir and valacyclovir offer superior dosing convenience (three times daily) compared to acyclovir (five times daily), which improves adherence. 2, 3

Timing of Treatment Initiation

• Treatment must be started within 72 hours of rash onset for optimal efficacy 2, 3
• Antiviral therapy shortens viral shedding duration by 1-2 days and reduces acute pain intensity and duration 2
• Evidence suggests famciclovir provides superior acute pain relief compared to valacyclovir, particularly in patients ≥50 years old, with significant pain reduction by days 3-4 5

Impact on Postherpetic Neuralgia (PHN)

Famciclovir is the only oral antiviral proven to reduce the duration of postherpetic neuralgia 6:

• Famciclovir recipients lost PHN two times faster than placebo (P = 0.02 all patients; P = 0.004 patients ≥50 years) 6
• This translates to a 3.5-month reduction in median PHN duration for patients 50 years or older 6
• The median duration of PHN was reduced from 100 days to approximately 56 days in older patients 6

Special Populations and Situations

Severe Disease Requiring Hospitalization

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 7

Immunocompromised Patients

• Higher doses may be required: acyclovir 400 mg orally three to five times daily until clinical resolution 8
• For severe cases: intravenous acyclovir 5 mg/kg every 8 hours 8
• If lesions persist during treatment, suspect acyclovir resistance and consider foscarnet 40 mg/kg IV every 8 hours 9, 8

Renal Impairment

• Dose adjustment is mandatory based on creatinine clearance to prevent acute renal failure 1
• Acute renal failure may occur in patients with underlying renal disease receiving higher than recommended doses 1

Patients Who May Not Require Treatment

• Mild cases in younger, healthy individuals often do not require antiviral treatment 2
• However, given the proven benefit in reducing PHN duration, treatment should be strongly considered for all patients ≥50 years old 6

Important Contraindications and Warnings

• Do not use topical acyclovir—it is substantially less effective than oral therapy 9, 7
• Famciclovir is contraindicated in patients with known hypersensitivity to the product, its components, or penciclovir cream 1
• Avoid valacyclovir 8 grams per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 9

Safety Profile

• All three oral antivirals are generally well tolerated with minimal adverse events 10
• Most common adverse events: headache and nausea (occurring in <10% of patients) 10, 1
• Antiviral resistance remains rare (<0.5%) in immunocompetent patients 10
• Probenecid may increase penciclovir levels; monitor for toxicity if co-administered 1

Pain Management Considerations

• Pain in shingles may have burning, lancinating, or allodynic qualities and typically lasts 2-8 weeks 2
• Pain treatment should be tailored to the type and intensity experienced 2
• Famciclovir demonstrates significantly earlier pain reduction (days 3-4) compared to valacyclovir, particularly beneficial for patients with moderate symptoms 5