From the Guidelines
For shingles pain, I strongly recommend starting with antiviral medications like valacyclovir or famciclovir, as they have been shown to reduce pain duration and severity when started within 72 hours of rash appearance 1.
Treatment Approach
To manage shingles pain effectively, a combination approach is necessary. This includes:
- Over-the-counter medications such as acetaminophen (Tylenol) at 650mg every 6 hours or ibuprofen (Advil, Motrin) at 400-600mg every 6 hours for mild to moderate pain.
- Prescription medications like gabapentin (starting at 300mg once daily, increasing gradually to 300mg three times daily) or pregabalin (Lyrica, 75mg twice daily) for more severe pain, as they specifically target nerve pain 1.
- Antiviral medications such as valacyclovir (1000mg three times daily for 7 days) or famciclovir (500mg three times daily for 7 days) to reduce pain duration and severity, especially when started promptly 1.
Additional Relief Measures
Additional measures to provide relief include:
- Topical options like lidocaine patches (5%) applied to painful areas for up to 12 hours daily or capsaicin cream.
- Cool compresses and loose clothing to reduce discomfort.
Importance of Prompt Treatment
Prompt treatment is crucial as it can prevent postherpetic neuralgia, a condition where pain persists after the rash heals. The choice of medication should be based on the severity of the pain and the patient's overall health status, with a focus on minimizing morbidity, mortality, and improving quality of life.
From the FDA Drug Label
The recommended dosage of famciclovir tablets for the treatment of herpes zoster is 500 mg every 8 hours for 7 days. Gabapentin was evaluated for the management of postherpetic neuralgia (PHN) in two randomized, double-blind, placebo-controlled, multicenter studies.
For pain management of shingles, famciclovir can be used at a dose of 500 mg every 8 hours for 7 days. Additionally, gabapentin can be used for the management of postherpetic neuralgia, a possible complication of shingles, at doses titrated up to 1800 or 2400 mg/day in divided doses 2. Acyclovir can also be used to treat herpes zoster, with a recommended dose of 800 mg 5 times daily for 10 days, which has been shown to shorten the times to lesion scabbing, healing, and complete cessation of pain 3.
From the Research
Treatment Options for Shingles
- Antiviral medications such as acyclovir, valacyclovir, or famciclovir can be used to treat shingles, ideally within 72 hours of the development of the rash 4, 5, 6.
- These medications can help reduce the duration and intensity of the rash, as well as the pain associated with shingles 6.
- Valacyclovir and famciclovir have been shown to be effective in reducing pain scores and accelerating the resolution of zoster-associated pain 7.
- In addition to antiviral medications, adjunct medications such as opioid analgesics, tricyclic antidepressants, or corticosteroids may be used to relieve pain associated with acute herpes zoster 4.
Management of Postherpetic Neuralgia
- Postherpetic neuralgia is a common complication of shingles, characterized by pain in a dermatomal distribution that persists for at least 90 days after the acute infection 4, 5.
- Treatment options for postherpetic neuralgia include tricyclic antidepressants, gabapentin, pregabalin, long-acting opioids, or tramadol 4.
- Topical lidocaine or capsaicin cream may also be used as a second-line agent to manage postherpetic neuralgia 4.
- Immunization with the varicella zoster virus vaccine can help prevent herpes zoster and postherpetic neuralgia, and is recommended for adults 60 years and older 4, 5.