What is the recommended treatment for patients with shingles?

Treatment of Shingles (Herpes Zoster)

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

First-Line Antiviral Options

The three FDA-approved oral antivirals are equally effective, but differ in dosing convenience:

• Valacyclovir 1 gram three times daily for 7-10 days (preferred for better adherence) 1, 2
• Famciclovir 500 mg three times daily for 7-10 days (equivalent efficacy, better bioavailability than acyclovir) 1, 3
• Acyclovir 800 mg five times daily for 7-10 days (requires more frequent dosing, may reduce compliance) 1, 4

Timing is critical: Treatment must be initiated within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia. 1 Maximum benefit occurs when started within 48 hours. 1

Treatment Duration

Continue antiviral therapy until all lesions have completely scabbed—this is the key clinical endpoint, not an arbitrary 7-day duration. 1 If lesions remain active beyond 7-10 days, extend treatment accordingly. 1, 4

When to Escalate to Intravenous Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours for: 1

• Disseminated herpes zoster (multi-dermatomal or visceral involvement)
• Severely immunocompromised patients (HIV with CD4 <100, active chemotherapy, organ transplant recipients)
• Complicated facial zoster with suspected CNS involvement
• Severe ophthalmic disease
• Patients who cannot tolerate oral medications

For immunocompromised patients with disseminated disease, consider temporarily reducing immunosuppressive medications while on IV acyclovir. 1

Special Populations

Immunocompromised patients: May require higher oral doses (acyclovir 400 mg 3-5 times daily) or extended treatment duration beyond 7-10 days, as lesions continue to develop for 7-14 days and heal more slowly. 1 Without adequate therapy, some develop chronic ulcerations with persistent viral replication. 1

Facial/ophthalmic involvement: Requires urgent treatment due to risk of vision loss and cranial nerve complications. Consider ophthalmology referral for any eye involvement. 1

Renal impairment: Mandatory dose adjustments for all antivirals to prevent acute renal failure. Monitor renal function closely during IV acyclovir therapy. 1

Pain Management

Combine antivirals with appropriately dosed analgesics plus a neuroactive agent (amitriptyline) for acute zoster pain. 5 Topical anesthetics provide minimal benefit and are not recommended as primary therapy. 1

Common Pitfalls to Avoid

• Never use topical acyclovir—it is substantially less effective than oral therapy and not recommended. 1, 4
• Do not underdose: Acyclovir 400 mg three times daily is only appropriate for genital herpes or HSV suppression, not shingles. 1
• Do not stop at 7 days if lesions haven't scabbed—treatment must continue until complete crusting occurs. 1
• Do not delay treatment waiting for laboratory confirmation in typical presentations—diagnosis is clinical. 1

Infection Control

Patients must avoid contact with susceptible individuals (pregnant women, immunocompromised persons, those without chickenpox immunity) until all lesions have crusted, as lesions are contagious. 1

Prevention

The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior shingles episodes. 1 Ideally administer before initiating immunosuppressive therapies. The live-attenuated vaccine (Zostavax) is contraindicated in immunocompromised patients. 1