From the Guidelines
The treatment for herpes zoster (shingles) is antiviral therapy, specifically oral valacyclovir or famciclovir for uncomplicated cases, and intravenous acyclovir for complicated cases.
Treatment Details
- For uncomplicated herpes zoster, oral valacyclovir or famciclovir are recommended, with treatment initiated within 72 hours of rash onset and continued for a minimum of 7-10 days 1.
- For complicated cases, such as multi-dermatomal, ophthalmic, visceral, or disseminated herpes zoster, intravenous acyclovir is the recommended treatment 1.
- In immunocompromised patients, antiviral therapy is crucial to prevent complications and should be started promptly 2, 1.
Key Considerations
- Timing of treatment is important, with initiation within 72 hours of rash onset recommended for optimal efficacy 1.
- Immunosuppressive therapy may need to be withheld in severe cases of varicella infection, disseminated HSV and VZV, and other severe infections, and restarted after the patient has commenced anti-VZV therapy and the skin vesicles have resolved 1.
- Resistance to antiviral therapy should be suspected in patients with persistent lesions despite appropriately dosed antiviral therapy, particularly in those with a history of repeated antiviral therapy for recurrent disease 1.
From the Research
Treatment Options for Herpes Zoster (Shingles)
- The current management of herpes zoster (HZ) involves the use of antiviral drugs and analgesics, which produce reasonable results in younger patients but are less effective in older patients, especially against postherpetic neuralgia (PHN) 3.
- Antiviral therapy is recommended for all immunosuppressed zoster patients if presentation occurs within 1 week of rash onset or any time before full crusting of lesions, with options including oral valaciclovir, famciclovir, or aciclovir 4.
- For localized disease, most patients can be treated with oral valaciclovir, famciclovir, or aciclovir, with close outpatient follow-up, while intravenous aciclovir therapy is reserved for those with disseminated varicella zoster virus infection, ophthalmic involvement, or severe immunosuppression 4.
- Oral valacyclovir 1.5 g twice daily has been shown to be safe and effective for the treatment of uncomplicated herpes zoster in immunocompetent patients over 18 years of age, with twice-daily dosing potentially increasing patient compliance and effectiveness of treatment 5.
Antiviral Agents
- Three oral antiviral agents are available for the treatment of herpes zoster: acyclovir, valacyclovir, and famciclovir, with meta-analysis showing that oral acyclovir significantly reduces herpes zoster-related symptoms and the duration, intensity, and prevalence of zoster-associated pain (ZAP) 6.
- The newer agents famciclovir and valacyclovir exhibit better oral bioavailability than acyclovir and have demonstrated similar efficacy to acyclovir with ZAP, requiring less frequent administration 6.
- Oral antiviral therapy of herpes zoster is beneficial in selected, elderly immunocompetent patients, reducing the duration and intensity of ZAP and providing more rapid skin lesion healing, and is also of benefit in immunocompromised patients with uncomplicated herpes zoster 6.
Management Strategies
- Current management strategies for herpes zoster and post-herpetic neuralgia include antiviral drugs, analgesic agents, anticonvulsants, tricyclic antidepressants, and topical therapies 7.
- New molecules in development show improved activity against varicella zoster virus (VZV), and new drug targets are being outlined, with the role of translational neuroscience being examined in moving towards a goal of finding disease-modifying treatments 7.