Treatment for Shingles (Herpes Zoster)
For immunocompetent adults with shingles, initiate oral valacyclovir 1 gram three times daily for 7 days, starting ideally within 72 hours of rash onset, and continue treatment until all lesions have completely scabbed. 1, 2, 3
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 days - preferred due to convenient dosing and superior pain reduction compared to acyclovir 2, 3, 4
- Famciclovir 500 mg three times daily for 7 days - equivalent efficacy to valacyclovir with similar dosing schedule 2, 5
- Acyclovir 800 mg five times daily for 7-10 days - effective but requires more frequent dosing which reduces compliance 1, 6
Critical timing: Treatment is most effective when initiated within 48-72 hours of rash onset, though benefits may still occur when started later 2, 7, 4
Treatment Duration and Endpoint
The key clinical endpoint is complete scabbing of all lesions, not an arbitrary 7-day duration. 2
- Continue antiviral therapy until all lesions have scabbed, which may require extending treatment beyond 7 days in some patients 1, 2
- Monitor for complete healing and extend therapy if lesions remain active 1, 2
Immunocompromised Patients: Escalate to IV Therapy
Immunocompromised patients require intravenous acyclovir 5-10 mg/kg every 8 hours for severe, disseminated, or complicated disease. 2, 8
Indications for IV acyclovir include:
- Disseminated herpes zoster (multi-dermatomal or visceral involvement) 2
- Severe immunosuppression (active chemotherapy, HIV with low CD4 count, organ transplant recipients) 2
- Complicated facial zoster with suspected CNS involvement 2
- Severe ophthalmic disease 2
Consider temporarily reducing immunosuppressive medications in patients with disseminated or invasive disease. 1, 2
Pain Management
Adequate analgesia is essential alongside antiviral therapy:
- Combine appropriately dosed analgesics with neuroactive agents (e.g., amitriptyline) during acute phase 7
- Valacyclovir and famciclovir provide superior pain reduction compared to acaclovir 4
- Narcotics may be required for severe acute pain 6
Adjunctive Corticosteroid Therapy: Limited Benefit
Corticosteroids provide only modest benefits in reducing acute pain and do NOT prevent postherpetic neuralgia. 1, 9
- Prednisone (starting at 40 mg daily, tapered over 3 weeks) may be considered as adjunctive therapy in select cases of severe, widespread disease 1, 9
- Avoid corticosteroids in immunocompromised patients due to increased risk of disseminated infection 1
- Contraindications include poorly controlled diabetes, severe osteoporosis, and history of steroid-induced psychosis 2
Common Pitfalls to Avoid
- Never use topical acyclovir - it is substantially less effective than oral therapy 1, 2
- Do not underdose - acyclovir 400 mg three times daily is only appropriate for genital herpes, NOT shingles 2
- Do not stop treatment prematurely - continue until all lesions have scabbed, not just for 7 days 1, 2
- Do not miss immunocompromised patients who require more aggressive IV therapy 1, 2
Special Populations
Facial/ophthalmic involvement: Requires urgent antiviral therapy due to risk of vision-threatening complications and cranial nerve involvement 2, 7
Renal impairment: Mandatory dose adjustments for all antivirals to prevent acute renal failure; monitor renal function closely during IV acyclovir 2
HIV-positive patients: May require higher oral doses (up to 800 mg 5-6 times daily) or IV therapy for severe disease 2
Infection Control
Patients must avoid contact with susceptible individuals (those who have not had chickenpox or vaccination) until all lesions have crusted. 2, 8
Prevention: Vaccination
The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes. 2 Ideally administer before initiating immunosuppressive therapies 2