What is the recommended treatment for a patient presenting with shingles, considering their age, medical history, and current health status?

Treatment of Shingles (Herpes Zoster)

For immunocompetent adults with uncomplicated shingles, initiate oral valacyclovir 1000 mg three times daily for 7 days within 72 hours of rash onset, continuing treatment until all lesions have completely scabbed. 1, 2

First-Line Antiviral Therapy

Standard Treatment Options

Oral antiviral therapy is the cornerstone of shingles management and should be initiated as soon as possible after diagnosis. The three FDA-approved options are:

• Valacyclovir 1000 mg three times daily for 7 days - this 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 postherpetic neuralgia compared to acyclovir 2, 3, 4

• Famciclovir 500 mg three times daily for 7 days - equally effective to valacyclovir with similar bioavailability advantages over acyclovir, and the only oral antiviral proven to reduce duration of postherpetic neuralgia when administered during acute infection 5, 4

• 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 Considerations

• Treatment must be initiated within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia 1, 3

• Treatment is most effective when started within 48 hours of rash onset 2

• However, observational data suggest valacyclovir may still provide benefit when started beyond 72 hours, particularly for pain reduction, so do not withhold treatment if the patient presents late 4

Treatment Duration and Endpoint

• Continue antiviral therapy until all lesions have completely scabbed, not just for an arbitrary 7-day period - this is the key clinical endpoint 1

• If lesions are still forming or have not completely scabbed at 7 days, extend treatment duration 1

• Immunocompromised patients may require treatment extension well beyond 7-10 days as their lesions develop over longer periods (7-14 days) and heal more slowly 1

Escalation to Intravenous Therapy

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

• Disseminated herpes zoster (multi-dermatomal involvement, visceral involvement) 1

• Severely immunocompromised patients (active chemotherapy, HIV with low CD4 count, solid organ transplant recipients) 1

• Complicated facial zoster with suspected CNS involvement or severe ophthalmic disease 1

• Severe disease requiring hospitalization (encephalitis, pneumonitis, hepatitis) 7

• Continue IV therapy for a minimum of 7-10 days and until clinical resolution is attained (all lesions completely scabbed) 1

Special Considerations for Immunocompromised Patients

• For immunocompromised patients with uncomplicated herpes zoster, consider higher oral doses: acyclovir 400 mg orally 3-5 times daily until clinical resolution 7, 1

• Temporarily reduce immunosuppressive medications in patients with disseminated or invasive herpes zoster 1

• Monitor renal function closely during IV acyclovir therapy, with dose adjustments as needed for renal impairment 1

• If lesions persist despite acyclovir treatment, suspect resistance and obtain viral culture with susceptibility testing 1

Management of Acyclovir-Resistant Cases

For proven or suspected acyclovir-resistant herpes zoster, switch to foscarnet 40 mg/kg IV every 8 hours until clinical resolution. 7, 1

• All acyclovir-resistant strains are also resistant to valacyclovir, and most are resistant to famciclovir 1

• Acyclovir resistance should be suspected in immunocompromised patients whose lesions fail to begin resolving within 7-10 days of treatment 1

• Topical cidofovir gel 1% applied once daily for 5 consecutive days may be an alternative option 1

Common Pitfalls to Avoid

• Never use topical antiviral therapy - it is substantially less effective than systemic therapy and is not recommended 1

• Do not use the 400 mg TDS acyclovir dose for shingles - this dose is only appropriate for genital herpes or HSV suppression in HIV patients, not for varicella-zoster virus infection 1

• Do not apply corticosteroid creams to active shingles lesions - this can increase risk of severe disease and dissemination, particularly in immunocompromised patients 1

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

Age-Specific Considerations

Patients ≥50 Years of Age

• This population is at greatest risk for postherpetic neuralgia, making prompt antiviral therapy particularly critical 6, 5

• Valacyclovir and famciclovir are superior to acyclovir for pain reduction in this age group 1

• Famciclovir reduced median duration of postherpetic neuralgia by 100 days (3.5 months) in patients ≥50 years compared to placebo 5

Immunocompromised Patients

• For patients on active chemotherapy (e.g., daratumumab, bortezomib, melphalan, prednisone), initiate immediate intravenous acyclovir 10 mg/kg every 8 hours due to high risk of dissemination and vision-threatening complications 1

• Consider acyclovir or valacyclovir prophylaxis (400 mg daily) for patients receiving proteasome inhibitor-based therapies to prevent herpes zoster 1

Prevention with Vaccination

All adults aged 50 years and older should receive the recombinant zoster vaccine (Shingrix) as a two-dose series (second dose 2-6 months after first dose), regardless of prior herpes zoster episodes. 7, 1, 8, 9

• Shingrix demonstrates 97.2% efficacy in preventing herpes zoster in adults aged 50 years and older 8

• Protection persists for at least 8 years with minimal waning, maintaining efficacy above 83.3% 8

• Vaccination should occur after recovery from acute shingles, waiting at least 2 months after acute symptoms resolve 8, 9

• Having had shingles once does not provide reliable protection against future episodes (10-year cumulative recurrence risk of 10.3%) 8

• Adults who previously received Zostavax should still receive the full 2-dose Shingrix series at least 2 months after Zostavax, as the older vaccine's efficacy declines to only 14.1% by year 10 8, 9

• For immunocompromised adults aged ≥18 years, use a shorter schedule with the second dose given 1-2 months after the first dose 8

• Shingrix is safe for immunocompromised patients, unlike the live-attenuated Zostavax which is contraindicated in this population 8, 9

Infection Control

• Patients with shingles should avoid contact with susceptible individuals (those who have not had chickenpox) until all lesions have crusted 1

• Lesions are contagious and can transmit varicella-zoster virus to non-immune individuals 1

Post-Exposure Prophylaxis

• For varicella-susceptible patients exposed to active varicella zoster infection, administer varicella zoster immunoglobulin (VZIG) within 96 hours of exposure 1

• If immunoglobulin is not available or more than 96 hours have passed, give a 7-day course of oral acyclovir beginning 7-10 days after varicella exposure 1