What is the recommended treatment for a patient with shingles?

Treatment of Shingles (Herpes Zoster)

For uncomplicated shingles, start oral valacyclovir 1000 mg three times daily for 7 days, initiated within 72 hours of rash onset, and continue treatment until all lesions have completely scabbed. 1, 2

First-Line Oral Antiviral Options

Valacyclovir is the preferred first-line agent due to superior bioavailability (3-5 fold higher than acyclovir), more convenient dosing, and proven superiority in reducing duration of zoster-associated pain compared to acyclovir. 3, 4, 5

Standard Dosing Regimens:

• Valacyclovir 1000 mg orally three times daily for 7 days (preferred) 1, 2
• Famciclovir 500 mg orally three times daily for 7 days (equivalent efficacy to valacyclovir) 6, 5
• Acyclovir 800 mg orally five times daily for 7-10 days (requires more frequent dosing, less convenient) 1, 7

Critical Timing and Duration Principles

Initiate treatment within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia. 1, 7 However, treatment started beyond 72 hours may still provide benefit, particularly for pain reduction. 5

Continue treatment until all lesions have completely scabbed, not just for an arbitrary 7-day period. 1 This is the key clinical endpoint—if lesions remain active beyond 7 days, extend treatment duration accordingly. 1

Escalation to Intravenous Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours for the following situations: 1

• Disseminated or invasive herpes zoster (multi-dermatomal, visceral involvement)
• Immunocompromised patients (HIV, chemotherapy, chronic immunosuppression)
• Severe disease requiring hospitalization
• CNS complications (encephalitis, meningitis)
• Complicated ocular disease (herpes zoster ophthalmicus with vision-threatening features)

For immunocompromised patients, consider temporary reduction in immunosuppressive medications during treatment of disseminated disease. 1

Special Populations

Immunocompromised Patients:

• Uncomplicated disease: Oral valacyclovir or acyclovir at standard doses 1
• Disseminated/invasive disease: IV acyclovir 10 mg/kg every 8 hours with temporary reduction of immunosuppression 1
• Treatment duration: Continue for minimum 7-10 days and until complete lesion crusting; may require extended therapy beyond 10 days as lesions develop over longer periods (7-14 days) and heal more slowly 1

Renal Impairment:

Dose adjustments are mandatory to prevent acute renal failure. 1 Monitor renal function at initiation and once or twice weekly during IV therapy. 1

Facial/Ophthalmic Involvement:

Facial zoster requires urgent treatment due to risk of cranial nerve complications and vision loss. 1 Consider ophthalmology referral for suspected ocular involvement. 7

Adjunctive Therapies

Corticosteroids:

Prednisone may provide modest benefit in reducing acute pain when added to antivirals in select cases of severe, widespread disease. 1 However, avoid corticosteroids in immunocompromised patients due to increased risk of disseminated infection. 1

Do not use topical corticosteroids on active shingles lesions, as this can worsen infection and increase dissemination risk. 1

Pain Management:

• Neuropathic pain agents (tricyclic antidepressants, gabapentin, pregabalin) for postherpetic neuralgia 7
• Narcotics may be required for adequate acute pain control 7
• Topical lidocaine patches for localized pain 7

Critical Pitfalls to Avoid

Never use topical acyclovir for shingles—it is substantially less effective than systemic therapy and is not recommended. 1

Do not discontinue treatment at exactly 7 days if lesions are still forming or have not completely scabbed. 1 Short-course therapy designed for genital herpes is inadequate for VZV infection. 1

Do not apply any topical products to active vesicular lesions; wait until lesions have crusted before using emollients. 1

Acyclovir-Resistant Cases

For proven or suspected acyclovir resistance (lesions persisting despite adequate treatment, particularly in immunocompromised patients): 1

• Foscarnet 40 mg/kg IV every 8 hours until clinical resolution 1
• All acyclovir-resistant strains are also resistant to valacyclovir and most to famciclovir 1

Prevention

The recombinant zoster vaccine (Shingrix) is recommended for all adults aged 50 years and older, regardless of prior herpes zoster episodes, to prevent future occurrences. 1 Ideally administer before initiating immunosuppressive therapies. 1

Infection Control

Patients should avoid contact with susceptible individuals (those who have not had chickenpox, pregnant women, immunocompromised persons) until all lesions have crusted, as lesions are contagious. 1