Treatment of Facial Shingles in Older Adults
Initiate oral valacyclovir 1000 mg three times daily immediately, ideally within 72 hours of rash onset, and continue treatment until all lesions have completely scabbed—not just for an arbitrary 7-day period. 1, 2, 3
First-Line Antiviral Therapy
Valacyclovir is the preferred agent due to superior bioavailability and less frequent dosing compared to acyclovir, which improves adherence in older adults. 1, 3
- Valacyclovir 1000 mg three times daily for 7-10 days is the standard regimen 1, 3, 4
- Alternative option: Acyclovir 800 mg five times daily for 7-10 days if valacyclovir is unavailable 1, 2
- Alternative option: Famciclovir 500 mg three times daily for 7-10 days offers comparable efficacy 1
Critical timing: Treatment must begin within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia. 1, 2, 3
Special Urgency for Facial Involvement
Facial shingles requires particular attention due to high-risk complications: 2
- Ramsay Hunt syndrome (herpes zoster oticus): facial paralysis, ear pain, vesicles in ear canal 1
- Herpes zoster ophthalmicus: vision-threatening complications including keratitis, iridocyclitis, secondary glaucoma, and potential vision loss 5
- Cranial nerve involvement: motor neuropathies affecting facial, trigeminal, or geniculate ganglia 5, 2
Urgent ophthalmology referral is mandatory if there are vesicles on the tip of the nose (Hutchinson's sign), periorbital involvement, or any visual symptoms. 5
Treatment Endpoint: Complete Scabbing
Do not stop antiviral therapy at exactly 7 days if lesions are still forming or have not completely scabbed. The key clinical endpoint is complete scabbing of all lesions, not an arbitrary calendar duration. 1, 2, 3
When to Escalate to Intravenous Therapy
Switch to intravenous acyclovir 10 mg/kg every 8 hours if any of the following occur: 1, 2, 3
- Disseminated herpes zoster (multi-dermatomal or visceral involvement)
- Suspected CNS involvement (encephalitis, meningitis)
- Severe immunocompromise (HIV with CD4 <200, active chemotherapy, high-dose immunosuppression)
- Complicated ophthalmic disease with suspected intraocular involvement
- Inability to take oral medications
- Failure to respond to oral therapy within 7-10 days
Continue IV therapy for a minimum of 7-10 days and until clinical resolution is attained. 2, 3
Adjunctive Pain Management
Avoid oral corticosteroids in routine cases. While they may provide modest short-term pain reduction, they carry significant risks (infections, hypertension, myopathy, glaucoma, osteopenia) that outweigh benefits, especially in older adults who are most susceptible to shingles. 2, 6, 7
- Acetaminophen or NSAIDs for mild pain
- Opioids for severe acute pain
- Gabapentin or pregabalin for neuropathic pain
Monitoring and Follow-Up
- Monitor renal function at initiation and weekly during treatment, as dose adjustments are mandatory in renal impairment to prevent acute renal failure 2
- If lesions fail to resolve within 7-10 days despite appropriate therapy, suspect acyclovir resistance, obtain viral culture with susceptibility testing, and switch to foscarnet 40 mg/kg IV every 8 hours 1, 2
Infection Control
Patients must avoid contact with susceptible individuals (pregnant women who are varicella-seronegative, immunocompromised persons, infants who haven't had chickenpox) until all lesions have crusted, as the virus can be transmitted and cause varicella in susceptible contacts. 1, 2, 3
Prevention of Future Episodes
The recombinant zoster vaccine (Shingrix) is strongly recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes, which reduces shingles incidence by approximately 90%. 5, 1, 2, 3