What is the treatment for Herpes zoster (shingles)?

From the Guidelines

Herpes zoster treatment should begin as soon as possible after symptoms appear, ideally within 72 hours of rash onset, with antiviral medications such as acyclovir or famciclovir being the first-line treatment. The goal of treatment is to reduce the severity and duration of the outbreak, as well as decrease the risk of developing postherpetic neuralgia, a common complication characterized by persistent pain after the rash resolves. According to a study published in MMWR Recommendations and Reports 1, two nucleoside analogs, acyclovir and famciclovir, have been approved by FDA for treating HZ, with similar efficacy when administered within 72 hours of rash onset.

Some key points to consider when treating herpes zoster include:

• Starting treatment as soon as possible after symptoms appear, ideally within 72 hours of rash onset
• Using antiviral medications such as acyclovir or famciclovir as first-line treatment
• Managing pain with medications such as acetaminophen, NSAIDs, gabapentin, or pregabalin
• Keeping the rash clean and covered to prevent secondary bacterial infection and transmission
• Considering corticosteroids in severe cases or for older patients, but using them cautiously

It's worth noting that valacyclovir and famciclovir are generally preferred due to better bioavailability and simpler dosing schedules, but the study published in MMWR Recommendations and Reports 1 only mentions acyclovir and famciclovir. The treatment should be tailored to the individual patient's needs and medical history, with the goal of reducing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

Herpes Zoster VALTREX is indicated for the treatment of herpes zoster (shingles) in immunocompetent adults. The efficacy of VALTREX when initiated more than 72 hours after the onset of rash and the efficacy and safety of VALTREX for treatment of disseminated herpes zoster have not been established.

Herpes Zoster (Shingles) There are no data on treatment initiated more than 72 hours after onset of zoster rash Patients should be advised to initiate treatment as soon as possible after a diagnosis of herpes zoster.

Herpes Zoster Infections : Acyclovir tablets is indicated for the acute treatment of herpes zoster (shingles).

• Treatment Options:
  • Valacyclovir (PO) is indicated for the treatment of herpes zoster (shingles) in immunocompetent adults 2.
  • Famciclovir (PO) is used to treat shingles (herpes zoster) in adults with a normal immune system 3.
  • Acyclovir (PO) is indicated for the acute treatment of herpes zoster (shingles) 4.
• Key Considerations:
  • Initiate treatment as soon as possible after diagnosis 3.
  • Efficacy of valacyclovir when initiated more than 72 hours after onset of rash has not been established 2.
  • No data on treatment initiated more than 72 hours after onset of zoster rash for famciclovir 3.

From the Research

Treatment Options for Herpes Zoster

• Valaciclovir is an effective treatment for herpes zoster, with studies showing it to be at least as effective as aciclovir in controlling symptoms and alleviating zoster-associated pain and postherpetic neuralgia 5.
• Famciclovir is also a viable treatment option, with similar efficacy to valaciclovir in speeding resolution of acute herpes zoster rash and shortening the duration of postherpetic neuralgia 5, 6.
• Antiviral therapy, including aciclovir, valaciclovir, and famciclovir, can accelerate rash healing and limit the severity and duration of pain, with recommended use within 7 days of rash onset 7.

Dosage and Efficacy

• A dosage of 1000 mg valaciclovir three times daily for 7 days is a well-tolerated and effective treatment regimen for herpes zoster 5.
• Compared to aciclovir, valaciclovir has shown significant reduction in herpes-zoster-associated pain, with a 36% reduction in risk of pain at 21-30 days 6.
• Famciclovir has also demonstrated superiority to aciclovir, with a 46% reduction in risk of pain at 28-30 days 6.

Patient Characteristics and Antiviral Use

• Antiviral prescription patterns vary by patient characteristics, with older adults and immunosuppressed patients more likely to receive antiviral therapy 7.
• However, antiviral therapies for zoster are often under-prescribed, even among high-risk groups such as immunosuppressed and older individuals 7.

Safety and Tolerability

• Valaciclovir has a similar adverse events profile to aciclovir and famciclovir, with nausea and headache being the most commonly reported adverse events 5.
• Valaciclovir is generally well-tolerated, with a established place in the treatment of immunocompetent patients with herpes zoster 5, 8.