What is the appropriate treatment for a 79‑year‑old woman with acute herpes zoster?

Treatment of Shingles in a 79-Year-Old Female

For a 79-year-old woman with acute herpes zoster, initiate oral valacyclovir 1000 mg three times daily for 7–10 days, starting as soon as possible and ideally within 72 hours of rash onset, continuing until all lesions have completely scabbed. 1, 2

First-Line Oral Antiviral Therapy

• Valacyclovir 1000 mg orally three times daily for 7–10 days is the preferred first-line treatment for uncomplicated herpes zoster in this age group, offering superior bioavailability and more convenient dosing than acyclovir. 1, 2, 3

• Acyclovir 800 mg orally five times daily for 7–10 days is an acceptable alternative if valacyclovir is unavailable, though the five-times-daily dosing may reduce adherence in elderly patients. 1, 2

• Famciclovir 500 mg orally three times daily for 7–10 days demonstrates similar efficacy to valacyclovir and may be used as an alternative, particularly if gastrointestinal intolerance occurs with other agents. 1, 3

• Treatment must be initiated within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia, though observational data suggest benefit even when started later. 1, 3, 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 that determines treatment completion. 1, 2

• In elderly or immunocompromised patients, lesions may continue to develop for longer periods and heal more slowly, potentially requiring treatment extension beyond 7–10 days. 1

When to Escalate to Intravenous Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours if any of the following are present: 1, 2

• Disseminated herpes zoster (≥3 dermatomes, visceral involvement, or hemorrhagic lesions)

• Severe immunosuppression (active chemotherapy, organ transplant, HIV with low CD4 count)

• CNS complications (encephalitis, meningitis, Guillain-Barré syndrome)

• Complicated facial/ophthalmic involvement with suspected CNS extension

• Failure to improve within 7–10 days on oral therapy

• Continue IV acyclovir for a minimum of 7–10 days and until clinical resolution (all lesions scabbed), then consider switching to oral therapy once clinical improvement occurs. 1, 2

Special Considerations in Elderly Patients

• Elderly patients (≥65 years) are at higher risk for postherpetic neuralgia and experience longer duration of pain after healing compared to younger adults. 5

• Renal function must be assessed before initiating therapy and monitored during treatment, as elderly patients are more likely to have reduced renal function requiring dose adjustment. 1, 5

• Nausea, vomiting, dizziness, somnolence, hallucinations, confusion, and coma are reported more frequently in elderly patients receiving acyclovir or valacyclovir. 5

• Ensure adequate hydration during systemic antiviral therapy to reduce the risk of crystalluria and acyclovir-induced nephropathy. 1

Pain Management

• Gabapentin is the first-line oral agent for acute neuropathic pain due to herpes zoster, titrated in divided doses up to 2400 mg per day, though somnolence occurs in approximately 80% of treated individuals. 1

• Over-the-counter analgesics such as acetaminophen and ibuprofen are recommended for acute pain relief. 1

• Topical lidocaine patches and capsaicin (8% patch or cream) may provide adjunctive analgesia, particularly for localized pain. 1

• Corticosteroids (prednisone) may be considered as adjunctive therapy in select cases of severe, widespread shingles, but carry significant risks in elderly patients, including increased susceptibility to infections, hypertension, osteoporosis, and hyperglycemia. 1

Monitoring and Follow-Up

• Monitor for complete healing of all lesions and assess for development of postherpetic neuralgia (pain persisting >90 days after rash onset). 1

• If lesions have not begun to resolve within 7–10 days, suspect acyclovir resistance and obtain viral culture with susceptibility testing. 1

• For confirmed acyclovir-resistant VZV, switch to foscarnet 40 mg/kg IV every 8 hours until clinical resolution. 1, 2

Infection Control

• The patient should avoid contact with susceptible individuals (those who have not had chickenpox or vaccination) until all lesions have crusted, as lesions are contagious. 1

• Cover lesions with clothing or dressings to minimize transmission risk. 1

Prevention of Future Episodes

• After recovery from the current episode, administer the recombinant zoster vaccine (Shingrix) in a two-dose series, which provides >90% efficacy in preventing future herpes zoster episodes and is recommended for all adults ≥50 years regardless of prior herpes zoster history. 1, 2, 4

Common Pitfalls to Avoid

• Do not use topical antiviral therapy, as 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—short-course therapy designed for genital herpes is inadequate for VZV infection. 1

• Do not delay treatment waiting for laboratory confirmation in typical presentations—clinical diagnosis is sufficient in immunocompetent patients with classic dermatomal rash. 1

• Do not apply corticosteroid creams directly to active shingles lesions, as this can increase the risk of dissemination and severe disease. 1