What is the recommended treatment for a patient diagnosed with shingles?

Treatment of Shingles (Herpes Zoster)

For uncomplicated shingles, initiate oral valacyclovir 1000 mg three times daily for 7 days, continuing until all lesions have completely scabbed, with treatment ideally started within 72 hours of rash onset but still beneficial if started later. 1

First-Line Antiviral Therapy

Oral antiviral agents are the cornerstone of shingles treatment:

• Valacyclovir 1000 mg three times daily for 7 days is the preferred first-line option due to superior bioavailability and convenient dosing 1, 2
• Famciclovir 500 mg three times daily for 7 days offers equivalent efficacy with less frequent dosing than acyclovir 1, 3
• Acyclovir 800 mg five times daily for 7-10 days remains effective but requires more frequent dosing 1, 4

The evidence strongly favors valacyclovir over acyclovir: it accelerates pain resolution significantly faster (median 38 days versus 51 days), reduces postherpetic neuralgia duration, and decreases the proportion of patients with pain persisting at 6 months (19.3% versus 25.7%) 5. Valacyclovir achieves three- to fivefold higher acyclovir bioavailability compared to oral acyclovir 6, 7, 5.

Critical Treatment Timing

• Initiate treatment within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia 1
• Treatment started after 72 hours may still provide benefit for pain reduction, though ideally therapy should begin as soon as possible 6
• Continue treatment until all lesions have completely scabbed, not just for an arbitrary 7-day period—this is the key clinical endpoint 1

Escalation to Intravenous Therapy

Switch to IV acyclovir 10 mg/kg every 8 hours for:

• Disseminated or invasive herpes zoster (multi-dermatomal involvement, visceral involvement) 1
• Severely immunocompromised patients (active chemotherapy, HIV with low CD4 counts, organ transplant recipients) 1
• CNS complications or complicated ocular disease 1
• Treatment duration: minimum 7-10 days and until complete clinical resolution 1

Consider temporary reduction in immunosuppressive medications in immunocompromised patients with disseminated disease if clinically feasible 1.

Special Populations

Immunocompromised Patients

• Uncomplicated herpes zoster: Oral acyclovir or valacyclovir at standard doses 1
• Disseminated/invasive disease: IV acyclovir 10 mg/kg every 8 hours with temporary reduction of immunosuppression 1
• May require extended treatment duration beyond 7-10 days as lesions develop over longer periods (7-14 days) and heal more slowly 1

Renal Impairment

• Mandatory dose adjustments to prevent acute renal failure 1
• For valacyclovir with creatinine clearance 30-49 mL/min: reduce frequency 2
• Monitor renal function closely during IV acyclovir therapy 1

Adjunctive Corticosteroid Therapy

Corticosteroids are NOT routinely recommended:

• Prednisone may be considered as adjunctive therapy in select cases of severe, widespread shingles 1
• A 21-day course of acyclovir plus prednisolone (40 mg daily, tapered over 3 weeks) showed only slight benefits over standard 7-day acyclovir therapy and did not reduce postherpetic neuralgia frequency 4
• Avoid in immunocompromised patients due to increased risk of disseminated infection 1
• Significant risks include infections, hypertension, myopathy, glaucoma, osteopenia, and Cushing syndrome 1

Treatment Caveats and Pitfalls

Common mistakes to avoid:

• Never use topical antiviral therapy alone—it is substantially less effective than systemic therapy 1
• Do not discontinue treatment at exactly 7 days if lesions are still forming or have not completely scabbed 1
• Do not use acyclovir 400 mg three times daily—this dose is only appropriate for genital herpes or HSV suppression, not shingles 1
• Monitor for acyclovir resistance if lesions persist despite treatment, particularly in immunocompromised patients 1

Acyclovir-Resistant Cases

For proven or suspected resistance:

• Foscarnet 40 mg/kg IV every 8 hours until clinical resolution is the treatment of choice 1
• All acyclovir-resistant strains are also resistant to valacyclovir, and most are resistant to famciclovir 1
• Resistance is extremely rare in immunocompetent patients but occurs more frequently in immunocompromised patients receiving prolonged suppressive therapy 1

Infection Control

• Patients must avoid contact with susceptible individuals until all lesions have crusted, as lesions are contagious to those who have not had chickenpox or vaccination 1
• Cover lesions with clothing or dressings to minimize transmission risk 1
• Healthcare workers with herpes zoster should be excluded from duty until all lesions dry and crust 1

Prevention After Recovery

The recombinant zoster vaccine (Shingrix) is strongly recommended:

• For all adults aged ≥50 years, regardless of prior herpes zoster episodes 1
• Provides >90% efficacy in preventing future recurrences 1
• Should be administered after recovery from the current episode 1
• Ideally given before initiating immunosuppressive therapies 1