Treatment of Uncomplicated Herpes Zoster
For uncomplicated herpes zoster in adults, initiate oral valacyclovir 1 gram three times daily for 7 days within 72 hours of rash onset. 1, 2, 3
First-Line Antiviral Therapy
Valacyclovir is the preferred first-line agent due to superior bioavailability and convenient dosing compared to acyclovir, while maintaining equivalent efficacy. 2, 4, 5
- Valacyclovir 1 gram orally three times daily for 7 days is the standard regimen for immunocompetent adults with uncomplicated herpes zoster. 1, 2, 3
- Treatment must be initiated within 72 hours of rash onset to maximize effectiveness in reducing pain duration, accelerating lesion healing, and preventing postherpetic neuralgia. 1, 2, 3
- Continue treatment until all lesions have completely scabbed, not just for an arbitrary 7-day period—if new lesions continue forming or healing is incomplete, extend therapy beyond 7 days. 1, 2, 6
Alternative Oral Antiviral Options
If valacyclovir is unavailable or not tolerated:
- Acyclovir 800 mg orally five times daily for 7 days is an acceptable alternative, though it requires more frequent dosing. 1, 2, 3
- Famciclovir 500 mg orally three times daily for 7 days is equally effective and offers convenient dosing, with proven efficacy in reducing postherpetic neuralgia duration. 2, 7, 8
Critical Timing Considerations
- The 72-hour window from rash onset is crucial—antiviral efficacy diminishes significantly when treatment is delayed beyond this timeframe. 1, 3, 8
- Even if the patient presents after 72 hours, treatment may still be considered if new lesions are actively forming or if the patient has risk factors for complications. 2, 9
Pain Management During Acute Phase
- Opioid analgesics, acetaminophen, or NSAIDs may be used for acute pain control during the active infection phase. 9
- Gabapentin or pregabalin can be initiated early if pain is severe, as these agents may help prevent progression to postherpetic neuralgia. 1
- Topical therapies are not recommended as primary treatment during the acute vesicular phase. 6
When to Escalate to Intravenous Therapy
Switch to intravenous acyclovir 5-10 mg/kg every 8 hours if any of the following develop: 1, 2, 6
- Disseminated herpes zoster (involvement of more than 3 dermatomes)
- Ophthalmic involvement with vision-threatening complications
- Central nervous system involvement
- Visceral organ involvement
- Severe immunocompromise (though this falls outside "uncomplicated" disease)
Common Pitfalls to Avoid
- Do not use topical acyclovir—it is substantially less effective than systemic therapy and is not recommended. 2, 6
- Do not stop treatment at exactly 7 days if lesions are still forming or have not completely scabbed; continue until clinical resolution. 1, 2, 6
- Do not delay treatment waiting for laboratory confirmation in typical presentations—herpes zoster is a clinical diagnosis in immunocompetent patients. 6
- Do not prescribe short-course regimens designed for genital herpes (such as 1-day or 3-day courses)—these are inadequate for varicella-zoster virus infection. 2
Infection Control
- Patients must avoid contact with susceptible individuals (those who have never had chickenpox or vaccination) until all lesions have crusted. 2, 6
- Cover lesions with clothing or dressings to minimize transmission risk. 6
- Lesions remain contagious and can transmit varicella to susceptible individuals through direct contact. 2, 6
Prevention of Future Episodes
- After recovery, administer recombinant zoster vaccine (Shingrix) for all adults aged 50 years and older, regardless of this prior episode. 10, 2, 8
- The vaccine provides over 90% efficacy in preventing future herpes zoster episodes and should be given as a 2-dose series at least 2-6 months apart. 10, 2