What is the treatment for Herpes zoster (shingles)?

From the Guidelines

Herpes zoster treatment should begin as soon as possible after symptom onset, ideally within 72 hours of rash appearance, with high-dose IV acyclovir being the treatment of choice for compromised hosts, and oral acyclovir, famciclovir, or valacyclovir for otherwise healthy hosts. The treatment approach depends on the patient's immune status, with immunocompromised patients requiring more aggressive therapy 1. For immunocompromised hosts, high-dose IV acyclovir is the preferred treatment, while for otherwise healthy hosts, oral antiviral medications such as acyclovir, famciclovir, or valacyclovir can be used 1.

Some key points to consider in the treatment of herpes zoster include:

• Early treatment reduces the duration and severity of acute symptoms and may decrease the risk of postherpetic neuralgia 1
• Oral acyclovir, famciclovir, and valacyclovir are beneficial for VZV infections in otherwise healthy hosts, but oral therapy should be reserved for mild cases of VZV disease in patients with transient immune suppression or as treatment to complete therapy once the patient has shown a clinical response to IV acyclovir 1
• Recipients of allogeneic blood and bone marrow transplants routinely take acyclovir or valacyclovir during the first year following transplant for the prevention of VZV and HSV reactivation 1
• Antiviral resistance should be investigated and taken into account in the selection of the empiric regimen if skin lesions suspicious of VZV or HSV develop in patients already taking antivirals 1

In terms of specific treatment regimens, the following can be considered:

• High-dose IV acyclovir for compromised hosts
• Oral acyclovir (800 mg five times daily for 7-10 days), valacyclovir (1000 mg three times daily for 7 days), or famciclovir (500 mg three times daily for 7 days) for otherwise healthy hosts
• Pain management with acetaminophen, NSAIDs, gabapentin, or pregabalin as needed
• Topical treatments like lidocaine patches or capsaicin cream for additional relief 1

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

Herpes Zoster Treatment Options

• Herpes zoster, also known as shingles, can be treated with antiviral medications such as valaciclovir, aciclovir, and famciclovir 5, 6, 7, 8.
• Valaciclovir has been shown to be at least as effective as aciclovir in controlling the symptoms of acute herpes zoster and alleviating zoster-associated pain and postherpetic neuralgia 5.
• Famciclovir has also been found to be effective in the treatment of herpes zoster, with similar efficacy to valaciclovir and aciclovir 6, 8.

Treatment Regimens

• The recommended regimen for valaciclovir is 1000 mg three times daily for 7 days 5.
• Famciclovir can be administered at a dose of 250 mg, 500 mg, or 750 mg three times daily, with similar efficacy among these doses 6, 8.
• Aciclovir can be administered at a dose of 800 mg five times daily 6, 8.

Efficacy and Safety

• Valaciclovir, famciclovir, and aciclovir have been found to be well-tolerated and safe in the treatment of herpes zoster, with similar adverse event profiles 5, 6, 7, 8.
• The efficacy of these medications in preventing postherpetic neuralgia is still a topic of debate, with some studies suggesting a potential benefit and others finding no significant effect 5, 6, 9.

Prevention and Management

• Immunization against herpes zoster is recommended for most adults 60 years and older to prevent the disease and postherpetic neuralgia 9.
• Adjunct medications such as opioid analgesics, tricyclic antidepressants, or corticosteroids may be used to relieve pain associated with acute herpes zoster 9.
• Treatment of postherpetic neuralgia may involve tricyclic antidepressants, gabapentin, pregabalin, long-acting opioids, or tramadol, as well as capsaicin cream or a lidocaine patch as second-line agents 9.