Treatment of Shingles (Herpes Zoster)
For uncomplicated shingles in immunocompetent patients, prescribe oral valacyclovir 1000 mg three times daily for 7 days, initiated as soon as possible and ideally within 72 hours of rash onset. 1, 2
First-Line Antiviral Options
You have three equally effective oral antiviral choices for uncomplicated shingles:
- Valacyclovir 1000 mg three times daily for 7 days – preferred due to superior bioavailability and convenient dosing 1, 2, 3
- Famciclovir 500 mg three times daily for 7 days – equivalent efficacy with better bioavailability than acyclovir 1, 4, 5
- Acyclovir 800 mg five times daily for 7-10 days – effective but requires more frequent dosing, which may reduce compliance 1, 6, 7
Continue treatment until all lesions have completely scabbed, not just for an arbitrary 7-day period. 1 If lesions remain active beyond 7 days, extend therapy until complete scabbing occurs. 1
Critical Timing Considerations
- Initiate treatment within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia 1, 8
- Treatment within 48 hours provides maximum benefit for pain reduction 1
- Evidence suggests valacyclovir may still be effective when started after 72 hours, though ideally begin as soon as possible 1, 3
When to Escalate to Intravenous Therapy
Switch to intravenous acyclovir 10 mg/kg every 8 hours for:
- Disseminated or invasive herpes zoster (multi-dermatomal, visceral involvement) 1
- Immunocompromised patients with severe disease 1, 9
- Complicated facial zoster with suspected CNS involvement 1
- Severe ophthalmic disease 1
- Patients who cannot tolerate oral medications 1
For immunocompromised patients, consider temporary reduction in immunosuppressive medications during treatment of disseminated disease. 1
Special Population Adjustments
Immunocompromised Patients (Uncomplicated Disease)
- May require higher oral doses or extended duration 1
- Consider acyclovir 400 mg orally 3-5 times daily until clinical resolution 1
- Monitor closely for signs of dissemination requiring IV therapy 9
Renal Impairment
- Mandatory dose adjustments to prevent acute renal failure 1
- Monitor renal function at initiation and once or twice weekly during IV therapy 1
Facial/Ophthalmic Involvement
- Requires urgent treatment due to risk of vision-threatening complications and cranial nerve involvement 1
- Consider ophthalmology referral for ocular involvement 8
What NOT to Do
- Never use topical antivirals – they are substantially less effective than systemic therapy 1, 6, 8
- Do not routinely add corticosteroids – they provide only modest benefits in acute pain reduction but carry significant risks (infections, hypertension, myopathy, glaucoma, osteopenia) that outweigh benefits in most patients 1, 7
- Avoid corticosteroids entirely in immunocompromised patients due to increased risk of disseminated infection 1
- Do not stop treatment at exactly 7 days if lesions are still forming or haven't scabbed 1
Monitoring and Follow-Up
- Assess for complete scabbing of all lesions as the treatment endpoint 1
- If lesions fail to resolve within 7-10 days, suspect acyclovir resistance and obtain viral culture with susceptibility testing 1
- For confirmed resistance, switch to foscarnet 40 mg/kg IV every 8 hours until clinical resolution 1
- Monitor renal function during IV acyclovir therapy 1
Infection Control
- Patients should avoid contact with susceptible individuals (those without chickenpox immunity) until all lesions have crusted, as lesions are contagious 1
- This is particularly important for pregnant women, immunocompromised individuals, and those who have never had chickenpox 1