What is the recommended treatment for shingles?

Treatment for Shingles (Herpes Zoster)

For immunocompetent adults with shingles, initiate oral antiviral therapy with 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 Oral Antiviral Options

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

• Valacyclovir 1 gram three times daily for 7 days is preferred due to superior bioavailability and convenient dosing 2, 3, 5
• Famciclovir 500 mg three times daily for 7 days offers equivalent efficacy with the same dosing frequency 2, 4, 6
• Acyclovir 800 mg five times daily for 7-10 days remains effective but requires more frequent dosing, which may reduce compliance 1, 2

Timing is critical: Initiate treatment within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia 2, 7. Treatment is most effective when started within 48 hours 2, 3.

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 2. If lesions remain active beyond 7 days, extend treatment accordingly 1, 2.

Escalation to Intravenous Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours for: 2

• Disseminated herpes zoster (multi-dermatomal or visceral involvement) 2
• Severely immunocompromised patients 2, 8
• CNS complications or severe ophthalmic disease 2
• Patients unable to tolerate oral medications 2

Special Populations Requiring Modified Management

Immunocompromised Patients

• Require more aggressive management with consideration for IV acyclovir 5 mg/kg every 8 hours for severe cases 1, 8
• Temporarily reduce immunosuppressive medications in cases of disseminated or invasive herpes zoster 2
• May require extended treatment duration beyond 7-10 days as lesions develop over longer periods (7-14 days) and heal more slowly 2
• High-dose IV acyclovir remains the treatment of choice for severely compromised hosts 2

Facial/Ophthalmic Involvement

• Requires particular urgency due to risk of vision-threatening complications and cranial nerve involvement 2, 7
• Consider ophthalmology referral for herpes zoster ophthalmicus 9

Renal Impairment

• Dose adjustments are mandatory to prevent acute renal failure 2
• Monitor renal function closely during IV acyclovir therapy 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 discontinue treatment at exactly 7 days if lesions are still forming or have not completely scabbed 2
• Do not use inadequate dosing (e.g., 400 mg TID is only appropriate for genital herpes, not shingles) 2
• Do not delay treatment beyond 72 hours when possible, though some benefit may still occur with later initiation 5

Adjunctive Pain Management

While antivirals address viral replication, pain control requires separate management:

• Appropriately dosed analgesics in combination with neuroactive agents (e.g., amitriptyline) are helpful when given with antiviral therapy 7
• Corticosteroids (prednisone) may provide modest benefits in reducing acute pain but should generally be avoided in immunocompromised patients due to increased risk of disseminated infection 1, 2

Patient Education and Infection Control

• Lesions are contagious to individuals who have not had chickenpox - patients should avoid contact with susceptible individuals until all lesions have crusted 2, 8
• Antiviral medications do not eradicate latent virus but help control symptoms and reduce complications 2
• Antivirals are not a cure for shingles 8, 4

Prevention

The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes, ideally before initiating immunosuppressive therapies 2

Monitoring During Treatment

• Monitor for complete healing of lesions; treatment may need extension if healing is incomplete 1, 2
• Monitor renal function at initiation and once or twice weekly during IV acyclovir treatment 2
• If lesions fail to resolve within 7-10 days, suspect acyclovir resistance and obtain viral culture with susceptibility testing 2
• For acyclovir-resistant cases, foscarnet 40 mg/kg IV every 8 hours is the treatment of choice 2