What is the recommended treatment for shingles?

Treatment of Shingles (Herpes Zoster)

For uncomplicated shingles, start oral valacyclovir 1 gram three times daily or famciclovir 500 mg three times daily within 72 hours of rash onset, continuing for 7-10 days until all lesions have completely scabbed. 1, 2, 3

First-Line Oral Antiviral Options

Valacyclovir is the preferred first-line agent due to superior bioavailability and convenient dosing:

• Dosing: 1 gram orally three times daily for 7 days 2
• Advantages: Better bioavailability than acyclovir, three times daily dosing improves adherence 1, 4
• Treatment endpoint: Continue until all lesions have scabbed, not just 7 days if lesions remain active 1, 5

Famciclovir is equally effective with similar convenience:

• Dosing: 500 mg orally three times daily for 7 days 3, 4
• Advantages: Three times daily dosing, comparable efficacy to valacyclovir 4, 6

Acyclovir remains an acceptable alternative but requires more frequent dosing:

• Dosing: 800 mg orally five times daily for 7-10 days 1, 5
• Disadvantage: Five times daily dosing reduces compliance 5, 4

Critical Timing

Initiate treatment within 48-72 hours of rash onset for maximum benefit 1, 4, 6. While most effective within 48 hours, treatment started up to 72 hours still provides significant benefit in reducing acute pain duration and preventing postherpetic neuralgia 1, 6. Treatment beyond 72 hours may still be warranted in high-risk patients (age >50, immunocompromised, facial involvement) 6.

Indications for Intravenous Acyclovir

Switch to IV acyclovir 10 mg/kg every 8 hours for:

• Disseminated or multi-dermatomal herpes zoster 1, 7
• Severely immunocompromised patients (active chemotherapy, HIV with low CD4 count) 1, 7
• CNS complications or visceral involvement 1, 5
• Complicated ophthalmic disease 1
• Failure to respond to oral therapy or inability to take oral medications 1, 7

Continue IV therapy for minimum 7-10 days and until clinical resolution is attained 1, 7. Monitor renal function closely during IV therapy with dose adjustments for renal impairment 1.

Special Populations

Immunocompromised patients require aggressive management:

• Uncomplicated disease: Oral valacyclovir or famciclovir, but consider higher doses or extended duration 1
• Disseminated/invasive disease: IV acyclovir 10 mg/kg every 8 hours with temporary reduction in immunosuppressive medications 1, 7
• HIV-positive patients: May require higher oral doses (acyclovir 800 mg 5-6 times daily) or IV therapy for severe disease 1
• Transplant recipients: Oral therapy for uncomplicated disease, IV for disseminated disease 1

Elderly patients (>50 years) have higher risk of postherpetic neuralgia:

• Antiviral therapy is urgently indicated regardless of severity 6
• Age and pain severity are the strongest predictors of persistent pain 8
• 30% still have pain at 6 weeks, 15.9% at 6 months, 9% at one year 8

Facial/ophthalmic involvement requires urgent treatment:

• Initiate valacyclovir 1 gram three times daily or famciclovir 500 mg three times daily immediately 1
• Consider ophthalmology referral for zoster ophthalmicus 9, 6
• Higher risk of cranial nerve complications 1

Renal Dosing Adjustments

Famciclovir adjustments based on creatinine clearance:

• CrCl ≥60 mL/min: 500 mg every 8 hours 1
• Dose reductions mandatory for CrCl <60 mL/min to prevent acute renal failure 1

Valacyclovir and acyclovir also require renal dose adjustments 2.

Adjunctive Pain Management

Combine antivirals with appropriate analgesia:

• Adequately dosed analgesics (including narcotics if needed) for acute pain 9, 6
• Consider neuroactive agents (amitriptyline) in combination with antivirals 6
• Topical anesthetics provide minimal benefit and are not recommended as primary therapy 1

Corticosteroids (prednisone) may provide modest benefit:

• May shorten acute pain duration but does not prevent postherpetic neuralgia 9, 6
• Avoid in immunocompromised patients due to dissemination risk 1
• Contraindicated in poorly controlled diabetes, severe osteoporosis, or history of steroid-induced psychosis 1

Common Pitfalls to Avoid

• Do not use topical acyclovir - substantially less effective than oral therapy 1, 5
• Do not stop treatment at 7 days if lesions remain active - continue until all lesions have scabbed 1, 5
• Do not underdose - inadequate dosing increases treatment failure and complication risk 5
• Do not delay treatment waiting for "72-hour window" - earlier is better, but treatment beyond 72 hours may still benefit high-risk patients 6
• Do not miss immunocompromised patients requiring IV therapy - they need more aggressive management 5

Infection Control

Patients are contagious until all lesions have crusted:

• Avoid contact with pregnant women, immunocompromised individuals, and those without prior varicella immunity 1, 7
• Lesions can transmit varicella to susceptible individuals 1, 7

Prevention

Recombinant zoster vaccine (Shingrix) is recommended:

• All adults ≥50 years regardless of prior herpes zoster episodes 1
• Ideally administer before initiating immunosuppressive therapies 1
• Can be given after recovery from acute episode to prevent recurrence 1