Treatment for Shingles
For immunocompetent adults with shingles, initiate oral valacyclovir 1 gram three times daily or famciclovir 500 mg three times daily for 7-10 days, continuing treatment until all lesions have completely scabbed. 1, 2, 3, 4
First-Line 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 is the preferred first-line agent due to superior bioavailability and convenient dosing schedule 2, 3, 5
- Famciclovir 500 mg three times daily offers equivalent efficacy with the same three-times-daily convenience 2, 4, 5
- Acyclovir 800 mg five times daily remains effective but requires more frequent dosing, which may reduce compliance 1, 2
Treatment must be initiated within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia. 2, 6 However, treatment started beyond 72 hours may still provide benefit, particularly for pain reduction. 5
Treatment Duration and Endpoint
- Continue antiviral therapy until all lesions have completely scabbed, not just for an arbitrary 7-day period. 2 This is the key clinical endpoint that should guide treatment duration.
- Standard treatment duration is 7-10 days, but may need extension if lesions remain active beyond this timeframe. 1, 2
- Monitor for complete resolution of lesions; treatment may need to be extended if healing is incomplete after the initial course. 1
Special Populations Requiring Escalation
Immunocompromised patients require more aggressive management:
- Intravenous acyclovir 10 mg/kg every 8 hours is indicated for severely immunocompromised patients, disseminated herpes zoster (multi-dermatomal or visceral involvement), or complicated disease with CNS involvement. 2, 7
- Consider temporary reduction in immunosuppressive medications in cases of disseminated or invasive herpes zoster. 2
- Treatment duration should extend at least until clinical resolution is attained, often requiring longer courses than immunocompetent patients. 2, 7
Facial/ophthalmic involvement requires urgent treatment:
- Initiate oral valacyclovir or famciclovir immediately due to risk of ophthalmic and cranial nerve complications. 2
- Consider IV acyclovir for complicated facial zoster with suspected CNS involvement or severe ophthalmic disease. 2
Critical Pitfalls to Avoid
- Never use topical acyclovir - it is substantially less effective than oral therapy and is not recommended. 1, 2
- Do not underdose or use inadequate treatment duration - this leads to treatment failure and increased risk of complications. 1
- Do not delay treatment - efficacy is highest when started within 48-72 hours of rash onset. 2, 6
- Do not stop treatment at 7 days if lesions are still active - continue until all lesions have scabbed. 2
Adjunctive Pain Management
- Appropriately dosed analgesics combined with neuroactive agents (such as amitriptyline) should be given alongside antiviral therapy for pain control. 6
- Corticosteroids (prednisone) may provide modest benefit in reducing acute zoster pain but should generally be avoided in immunocompromised patients due to increased risk of disseminated infection. 2, 8
Infection Control
- Patients must avoid contact with susceptible individuals (those who have not had chickenpox) until all lesions have crusted, as lesions are contagious. 2, 7
Prevention of Future Episodes
- The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes, ideally administered before initiating immunosuppressive therapies. 2