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 (or until all lesions have completely scabbed), ideally within 72 hours of rash onset but treatment remains beneficial even if started later. 1, 2

First-Line Antiviral Options for Immunocompetent Patients

Oral antiviral therapy is the cornerstone of shingles treatment and should be initiated as soon as possible:

• Valacyclovir 1000 mg three times daily for 7 days is the preferred first-line agent due to superior bioavailability (3-5 fold higher than acyclovir), less frequent dosing that improves adherence, and proven superiority in reducing duration of zoster-associated pain and postherpetic neuralgia compared to acyclovir 1, 2, 3, 4

• Famciclovir 500 mg three times daily for 7 days offers comparable efficacy to valacyclovir with convenient dosing and is the only oral antiviral proven to reduce postherpetic neuralgia duration by 3.5 months in patients ≥50 years 1, 5, 3

• Acyclovir 800 mg five times daily for 7-10 days remains effective but requires more frequent dosing (five times daily), which may reduce adherence 1, 2, 6

Critical timing principle: Treatment is most effective when started within 48-72 hours of rash onset, but observational data suggest valacyclovir remains beneficial even when started after 72 hours, so do not withhold treatment based solely on timing 1, 3

Treatment Duration and Endpoint

Continue antiviral therapy until all lesions have completely scabbed—this is the key clinical endpoint, not an arbitrary 7-day duration. 1

• In immunocompetent patients, lesions typically scab within 7-10 days, but treatment should be extended if active lesions persist beyond this timeframe 1
• Do not discontinue therapy at exactly 7 days if new lesions are still forming or existing lesions have not scabbed 1

Immunocompromised Patients: Escalate to IV Therapy

For immunocompromised patients (HIV, cancer, chemotherapy, chronic immunosuppression), start intravenous acyclovir 10 mg/kg every 8 hours immediately, continuing for minimum 7-10 days until complete clinical resolution. 1

Indications for IV acyclovir in any patient:

• Disseminated herpes zoster (multi-dermatomal involvement, visceral involvement) 1
• Complicated facial zoster with suspected CNS involvement 1
• Severe ophthalmic disease 1
• Inability to tolerate oral medications 1

For immunocompromised patients with uncomplicated dermatomal zoster: Consider higher oral doses (acyclovir 400 mg orally 3-5 times daily until clinical resolution) with close monitoring, though IV therapy is safer 1

Important management consideration: Temporarily reduce immunosuppressive medications in immunocompromised patients with disseminated or invasive herpes zoster 1

Special Populations and Situations

Facial/Ophthalmic Zoster

• Requires urgent ophthalmology referral due to risk of vision-threatening complications 1, 6
• Start valacyclovir 1000 mg three times daily or famciclovir 500 mg three times daily immediately, continuing until all lesions scab 1
• Elevation of affected area and keeping skin well-hydrated with emollients is recommended 1

Renal Impairment

• Creatinine clearance 30-49 mL/min: Valacyclovir 1000 mg twice daily 2
• Creatinine clearance 10-29 mL/min: Valacyclovir 1000 mg once daily 2
• Creatinine clearance <10 mL/min: Valacyclovir 500 mg once daily 2
• Monitor renal function closely during IV acyclovir therapy with dose adjustments as needed 1

Acyclovir-Resistant Cases

• Suspect resistance if lesions fail to improve after 7-10 days of appropriate antiviral therapy 1
• Switch to foscarnet 40 mg/kg IV every 8 hours until clinical resolution for proven or suspected acyclovir resistance 1
• All acyclovir-resistant strains are also resistant to valacyclovir and most to famciclovir 1

Adjunctive Corticosteroid Therapy: Limited Role

Corticosteroids provide only modest benefits and carry significant risks—use selectively only in severe, widespread cases in immunocompetent patients. 1, 7

• Prednisone (40 mg daily tapered over 3 weeks) may modestly reduce acute pain and accelerate healing during the first 7-14 days, but does NOT reduce postherpetic neuralgia 1, 7
• Absolute contraindications: Immunocompromised patients, disseminated infection, poorly controlled diabetes, severe osteoporosis, history of steroid-induced psychosis 1
• The risks (infections, hypertension, myopathy, glaucoma, osteopenia, Cushing syndrome) generally outweigh benefits in most patients 1

What NOT to Do: Common Pitfalls

• Never use topical antivirals alone—they are substantially less effective than systemic therapy and are not recommended 1
• Never apply topical corticosteroids to active shingles lesions—this increases risk of dissemination and severe disease, especially in immunocompromised patients 1
• Do not rely on clinical diagnosis alone in immunocompromised patients—obtain laboratory confirmation with PCR or viral culture 1
• Do not use short-course regimens designed for genital herpes (e.g., acyclovir 400 mg three times daily for 5 days)—these are inadequate for VZV infection 1

Infection Control

Patients must avoid contact with susceptible individuals (pregnant women, immunocompromised persons, those without prior chickenpox or vaccination) until all lesions have crusted, as lesions remain contagious. 1

Prevention of Future Episodes

After recovery, strongly recommend recombinant zoster vaccine (Shingrix) for all patients ≥50 years, regardless of this current episode, to prevent future recurrences with >90% efficacy. 1

• Two-dose series provides superior protection compared to live attenuated vaccine 1
• Ideally administer before initiating immunosuppressive therapies 1
• Live attenuated vaccines (Zostavax) are contraindicated in immunocompromised patients 1

Monitoring During Treatment

• Assess for complete healing of lesions at follow-up 1
• Monitor renal function at initiation and once or twice weekly during IV acyclovir therapy 1
• If lesions fail to resolve within 7-10 days, suspect acyclovir resistance and obtain viral culture with susceptibility testing 1
• In immunocompromised patients on high-dose therapy, assess for thrombotic thrombocytopenic purpura/hemolytic uremic syndrome 1