What is the best treatment for a patient with shingles (herpes zoster) who is still experiencing pain?

Management of Ongoing Pain in Shingles

For a patient with active shingles who is still experiencing pain, continue antiviral therapy (acyclovir 800 mg five times daily or valacyclovir 1 gram three times daily) until all lesions have completely scabbed over, and initiate gabapentin as first-line therapy for pain control, titrating to 2400 mg/day in divided doses. 1, 2

Antiviral Therapy: The Foundation

The critical endpoint for antiviral treatment is complete scabbing of all lesions, not an arbitrary 7-day duration. 1, 2 Many clinicians mistakenly stop antivirals after one week, but if lesions remain active, treatment must continue. 2

Standard antiviral regimens:

• Acyclovir 800 mg orally 5 times daily until all lesions scab 1, 2
• Valacyclovir 1 gram three times daily (superior bioavailability, better adherence) 1, 2
• Famciclovir 500 mg three times daily (alternative with better bioavailability) 1, 2

Early antiviral therapy is most effective when started within 72 hours of rash onset, but treatment should still be initiated even if this window has passed, particularly if new lesions are still forming. 3, 4

Pain Management During Active Shingles

First-Line: Gabapentin

Gabapentin is the recommended first-line agent for managing pain during active shingles and preventing progression to postherpetic neuralgia. 2, 5 The FDA label demonstrates efficacy in postherpetic neuralgia with reduction in pain scores seen as early as Week 1. 5

Dosing strategy:

• Start with 300 mg on day 1, then 300 mg twice daily on day 2, then 300 mg three times daily on day 3 5
• Titrate upward in 600-1200 mg/day increments every 3-7 days 5
• Target dose: 2400 mg/day in three divided doses (800 mg TID) 2, 5
• Maximum studied dose: 3600 mg/day 5

Second-Line: Pregabalin

If gabapentin provides inadequate relief or is poorly tolerated, pregabalin is an appropriate alternative. 6, 2 The FDA label shows efficacy in postherpetic neuralgia with pain reduction as early as Week 1. 7

Dosing:

• 75-150 mg twice daily or 50-100 mg three times daily 2, 7
• Titrate based on response and tolerability 7

Adjunctive Analgesics

• Acetaminophen up to 4 grams daily can be used as needed for additional pain control 5, 7
• Topical lidocaine patches may provide localized relief but should not be primary therapy 2, 8
• Avoid topical acyclovir entirely—it is substantially less effective than systemic therapy 1, 2

Role of Corticosteroids: Use With Caution

Prednisone may be added to antivirals in select cases of severe, widespread shingles to alleviate short-term pain. 2 However, corticosteroids carry significant risks, particularly in elderly patients who are most susceptible to shingles. 2

Contraindications to corticosteroids:

• Immunocompromised patients (increased risk of disseminated infection) 1, 2
• Poorly controlled diabetes 1
• History of steroid-induced psychosis 1
• Severe osteoporosis 1

When to Escalate to Intravenous Therapy

Switch to IV acyclovir 10 mg/kg every 8 hours if: 1, 2

• Disseminated herpes zoster (multi-dermatomal or visceral involvement) 1
• Facial zoster with suspected CNS involvement or severe ophthalmic disease 1
• Patient is severely immunocompromised 1
• Lesions persist despite adequate oral antiviral therapy (consider acyclovir resistance) 1

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

Special Considerations for Facial Involvement

Facial zoster requires particular attention due to risk of cranial nerve complications, including potential vision loss. 1, 2

Additional measures:

• Elevate the affected area to promote drainage of edema 1, 2
• Keep skin well hydrated with emollients to prevent dryness and cracking 1, 2
• Consider ophthalmology referral if periorbital involvement 8

Renal Dosing Adjustments

For patients with renal impairment, dose adjustments are mandatory to prevent acute renal failure. 2 Monitor renal function closely during IV acyclovir therapy. 1

Common Pitfalls to Avoid

• Never stop antivirals at 7 days if lesions remain active—continue until complete scabbing occurs 1, 2
• Do not use topical antivirals as primary therapy—they are substantially less effective 1, 2
• Avoid high-dose corticosteroids in elderly or immunocompromised patients without careful risk-benefit assessment 1, 2
• Do not rely on topical anesthetics as primary pain management—they provide minimal benefit during the active phase 2

Prevention of Future Episodes

Once the acute episode resolves, the recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes. 1, 2 Vaccination can be considered after recovery to prevent future episodes. 1, 2