What is the recommended treatment for herpes zoster (shingles) in an otherwise healthy adult, including antiviral therapy, pain management, and follow‑up care?

Treatment of Herpes Zoster (Shingles) in Otherwise Healthy Adults

For an otherwise healthy adult with shingles, initiate oral valacyclovir 1000 mg three times daily or famciclovir 500 mg three times daily within 72 hours of rash onset, continue until all lesions have completely scabbed, and manage acute pain with gabapentin titrated up to 2400 mg daily in divided doses. 1

Antiviral Therapy: First-Line Treatment

Start antiviral therapy within 72 hours of rash onset to maximize efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia. 1, 2 Treatment initiated within 48 hours provides optimal benefit, but the 72-hour window remains the standard cutoff. 1

Preferred Oral Regimens

• Valacyclovir 1000 mg three times daily for 7-10 days 1, 3
• Famciclovir 500 mg three times daily for 7-10 days 1, 3
• Acyclovir 800 mg five times daily for 7-10 days (alternative if others unavailable) 1, 3, 2

Valacyclovir and famciclovir offer superior bioavailability and less frequent dosing compared to acyclovir, which improves adherence. 1, 3 The five-times-daily acyclovir regimen is more cumbersome but remains effective. 1

Critical Treatment Endpoint

Continue antiviral therapy until all lesions have completely scabbed, not just for an arbitrary 7-day period. 1 If lesions are still forming or have not scabbed by day 7, extend treatment beyond the standard 7-10 days. 1 Short-course regimens (1-3 days) designed for genital herpes are inadequate for varicella-zoster infection and must be avoided. 1

When to Escalate to Intravenous Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours if any of the following develop: 1

• Disseminated herpes zoster (≥3 dermatomes, visceral involvement, or hemorrhagic lesions)
• CNS complications (encephalitis, meningitis, Guillain-Barré syndrome)
• Complicated ocular or facial disease
• Lesions fail to improve within 7-10 days on oral therapy

Pain Management

Acute Neuropathic Pain

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. 1 Counsel patients that somnolence occurs in approximately 80% of treated individuals. 1

• Start gabapentin at a low dose (e.g., 300 mg at bedtime) and titrate gradually to minimize side effects
• Target dose: 2400 mg daily in divided doses (e.g., 800 mg three times daily) 1
• Pregabalin may be added for patients whose pain remains uncontrolled with gabapentin alone 1

Adjunctive Analgesics

• Over-the-counter analgesics such as acetaminophen and ibuprofen for mild to moderate acute pain 1
• Application of topical ice or cold packs to reduce pain and swelling during the acute phase 1
• Topical anesthetics provide minimal benefit and are not recommended as primary therapy 1

Topical Therapies for Persistent Pain

• A single application of an 8% capsaicin patch (or 30-minute cream application) provides analgesia lasting at least 12 weeks for chronic peripheral neuropathic pain 1
• To mitigate burning, apply 4% lidocaine for 60 minutes, then remove before capsaicin administration 1

Special Considerations and Common Pitfalls

Facial or Ophthalmic Involvement

Facial zoster requires particular attention due to risk of cranial nerve complications and vision-threatening disease. 1 Initiate oral valacyclovir 1 gram three times daily or famciclovir 500 mg three times daily within 72 hours, with urgent ophthalmology referral if ocular involvement is suspected. 1, 4 A 7-day course of oral acyclovir (800 mg five times daily) is sufficient for herpes zoster ophthalmicus when started promptly. 4

Hydration and Renal Monitoring

Ensure adequate hydration during systemic acyclovir or valacyclovir therapy to reduce the risk of crystalluria and acyclovir-induced nephropathy. 1 For patients with renal impairment, dose adjustments are mandatory to prevent acute renal failure. 1

Topical Antivirals: Avoid

Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended. 1, 3

Corticosteroids: Limited Role

The addition of oral corticosteroids (e.g., prednisone) may provide modest benefits in reducing acute pain and the incidence of postherpetic neuralgia in select cases. 1, 2 However, corticosteroids carry significant risks—including increased susceptibility to infections, hypertension, myopathy, glaucoma, osteopenia, and Cushing syndrome—and their benefits do not outweigh these risks in most patients. 1 Avoid corticosteroids in immunocompromised patients due to increased risk of disseminated infection. 1

Infection Control

Patients with shingles should avoid contact with susceptible individuals (those who have not had chickenpox or vaccination) until all lesions have crusted. 1 Cover lesions with clothing or dressings to minimize transmission risk. 1 Lesions are contagious and can transmit varicella to non-immune individuals. 1

Follow-Up Care

• Monitor for complete healing of lesions 1, 3
• Assess for development of postherpetic neuralgia (pain persisting >90 days after rash onset) 2
• Watch for late ocular inflammatory complications if facial involvement occurred 4
• If lesions fail to begin resolving within 7-10 days, suspect acyclovir resistance and obtain viral culture with susceptibility testing 1

Prevention of Future Episodes

After recovery from the current episode, administer the recombinant zoster vaccine (Shingrix) for all adults aged 50 years and older, regardless of prior herpes zoster episodes. 1, 3 The two-dose series provides >90% efficacy in preventing future recurrences. 1, 5 Vaccination does not eliminate the need for treatment of active infection. 1