What is the best treatment for shingles?

Best Treatment for Shingles (Herpes Zoster)

For immunocompetent adults with shingles, start oral valacyclovir 1 gram three times daily for 7 days, initiated within 72 hours of rash onset, and continue treatment until all lesions have completely scabbed. 1, 2

First-Line Oral Antiviral Options

All three oral antivirals are FDA-approved and equally effective for treating shingles, but they differ in dosing convenience:

• Valacyclovir 1 gram three times daily for 7 days (preferred due to superior bioavailability and convenient dosing) 2, 3
• Famciclovir 500 mg three times daily for 7 days (equivalent efficacy with three-times-daily dosing) 1, 4, 5
• Acyclovir 800 mg five times daily for 7-10 days (requires more frequent dosing, which reduces adherence) 1, 2, 4

Valacyclovir and famciclovir are superior to acyclovir in clinical practice because their three-times-daily dosing improves patient adherence compared to acyclovir's five-times-daily regimen. 4, 3, 5 Valacyclovir also demonstrates faster resolution of zoster-associated pain and postherpetic neuralgia compared to acyclovir. 3

Critical Timing and Duration

• Initiate treatment within 72 hours of rash onset for maximum efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia. 1, 2, 6
• Treatment is most effective when started within 48 hours. 1, 2
• Continue antiviral therapy until all lesions have completely scabbed, not just for an arbitrary 7-day period. 1 This is the key clinical endpoint—if lesions remain active beyond 7 days, extend treatment duration. 1

When to Escalate to Intravenous Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours for: 1, 7

• Disseminated herpes zoster (multi-dermatomal or visceral involvement) 1
• Severely immunocompromised patients 1, 7
• Central nervous system complications 1
• Complicated ocular disease 1
• Patients who cannot tolerate oral medications 7

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

Special Populations Requiring Modified Approach

Immunocompromised patients (HIV, chemotherapy, organ transplant recipients):

• Consider immediate IV acyclovir due to high risk of dissemination 1
• May require extended treatment duration beyond 7-10 days as lesions develop over longer periods (7-14 days) and heal more slowly 1
• Temporarily reduce immunosuppressive medications if possible 1
• Without adequate antiviral therapy, some develop chronic ulcerations with persistent viral replication 1

Renal impairment: Dose adjustments are mandatory to prevent acute renal failure. 1 For valacyclovir with creatinine clearance 30-49 mL/min, reduce to 1 gram every 12 hours; for CrCl 10-29 mL/min, reduce to 1 gram every 24 hours. 2

Role of Corticosteroids (Use With Caution)

Corticosteroids are NOT routinely recommended for shingles treatment. 1, 6 While prednisone may provide modest short-term pain relief when added to antivirals, it carries significant risks, particularly in elderly patients who are most susceptible to shingles. 1, 6 Avoid corticosteroids entirely in immunocompromised patients due to increased risk of disseminated infection. 1

Common Pitfalls to Avoid

• Do not use topical antivirals—they are substantially less effective than systemic therapy and are not recommended. 8, 1
• Do not stop treatment at exactly 7 days if lesions are still forming or have not completely scabbed. 1 Short-course therapy designed for genital herpes is inadequate for varicella-zoster virus infection. 1
• Do not delay treatment beyond 72 hours—efficacy decreases significantly after this window. 1, 2
• Do not underdose in immunocompromised patients—they may require higher doses or IV therapy. 1

Infection Control

Patients with shingles should avoid contact with susceptible individuals (those who have not had chickenpox or vaccination) until all lesions have crusted, as lesions are contagious. 1, 7

Prevention for Future Episodes

The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes. 1 Vaccination should ideally occur before initiating immunosuppressive therapies. 1