What is the treatment for shingles?

Treatment for Shingles (Herpes Zoster)

For immunocompetent adults with shingles, start oral antiviral therapy with famciclovir 500 mg every 8 hours, valacyclovir 1000 mg twice daily, or acyclovir 800 mg five times daily for 7 days, initiated within 72 hours of rash onset for maximum benefit. 1, 2

Antiviral Therapy Selection

First-Line Oral Options (Immunocompetent Patients)

All three oral antivirals are FDA-approved and equally effective for shingles treatment, with the primary differences being dosing convenience 2, 3:

• Famciclovir 500 mg every 8 hours (three times daily) for 7 days - offers convenient dosing and may provide superior acute pain relief compared to valacyclovir, particularly in patients ≥50 years old 2, 4
• Valacyclovir 1000 mg twice daily for 7 days - most convenient dosing schedule with only twice-daily administration 5
• Acyclovir 800 mg five times daily for 7 days - requires more frequent dosing but remains effective 3, 6

Timing of Treatment Initiation

• Antiviral therapy must be started within 72 hours of rash onset to achieve maximum benefit in shortening viral shedding, accelerating lesion healing by 1-2 days, and reducing acute pain intensity and duration 3, 4
• Treatment initiated after 72 hours may still provide benefit, particularly for ongoing new lesion formation or in high-risk patients 4

Severe Disease and Hospitalized Patients

For patients requiring hospitalization due to severe disease:

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 1
• This includes patients with disseminated disease, ophthalmic involvement, or inability to tolerate oral medications 1

Immunocompromised Patients

Higher antiviral doses are required for immunocompromised patients 1:

• Acyclovir 400 mg orally three to five times daily until clinical resolution, OR
• Intravenous acyclovir 5 mg/kg every 8 hours 1
• If lesions persist during treatment, suspect acyclovir resistance and switch to foscarnet 40 mg/kg IV every 8 hours 1

Important Contraindications and Warnings

What NOT to Use

• Never use topical acyclovir - it is substantially less effective than oral therapy and should be avoided 1
• Avoid valacyclovir 8 grams per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 1

Renal Dosing Adjustments

• All three antivirals require dose reduction based on creatinine clearance in patients with renal impairment 2
• Failure to adjust doses in renal disease can lead to acute renal failure, particularly with higher doses 2

Safety Profile and Tolerability

• All three oral antivirals are generally well tolerated with minimal adverse events 1
• Most common side effects are headache and nausea, occurring in <10% of patients 1
• Antiviral resistance remains rare (<0.5%) in immunocompetent patients 1

Clinical Outcomes

Acute Phase Benefits

• Antivirals shorten duration of viral shedding and accelerate lesion healing by 1-2 days 3
• They reduce the intensity and duration of acute neuritic pain during the 2-8 week acute phase 3

Post-Herpetic Neuralgia (PHN) Prevention

• Famciclovir reduces the median duration of PHN by approximately 2-fold compared to placebo, translating to a 3.5-month reduction in patients ≥50 years old 7
• This represents the most clinically significant long-term benefit, as PHN is the primary cause of morbidity in shingles 7

Special Considerations

Mild Cases in Young Patients

• Mild cases of shingles in younger healthy individuals often do not require antiviral treatment 3
• However, treatment should still be considered to reduce transmission risk and prevent complications 3

Monitoring for Treatment Failure

• If lesions do not begin to resolve within 7-10 days of therapy, suspect acyclovir resistance 1
• This is more common in immunocompromised patients and requires switching to foscarnet 1