›Oral antivirals for uncomplicated disease
›Valacyclovir 1000 mg PO three times daily for 7 days
›Preferred for dosing convenience
›Renal dose adjustment required
›Famciclovir 500 mg PO three times daily for 7 days
›Alternative if valacyclovir unavailable
›Renal dose adjustment required
›Acyclovir 800 mg PO five times daily for 7 to 10 days
›Lower bioavailability
›Adherence barrier
›IV antivirals for severe disease
›Acyclovir 10 mg/kg IV every 8 hours
›Use ideal body weight if obese
›Dose adjust for renal function
›Ensure IV hydration to reduce nephrotoxicity
›Duration guidance
›Continue until clinical improvement
›Transition to oral to complete 10 to 14 days total for disseminated or CNS disease
›Evidence tags for antiviral use
›Class I recommendation for antivirals within 72 hours for immunocompetent adults
›Supported by randomized trial evidence
›Reduces acute pain duration
›ACEP Level B style evidence tag for early antiviral therapy
›Multiple RCTs and meta analyses support benefit
›Greatest effect early
Pain control and neuropathic therapy
›Baseline analgesics
›Acetaminophen 1000 mg PO every 6 hours as needed
›Maximum 3000 mg per day if older age or liver risk
›Avoid duplicate products
›Ibuprofen 400 mg PO every 6 to 8 hours as needed
›Maximum 2400 mg per day typical
›Avoid in CKD or GI bleed risk
›Neuropathic agents
›Gabapentin 300 mg PO at bedtime day 1
›Titrate to 300 mg PO twice daily day 2
›Titrate to 300 mg PO three times daily day 3
›Further titration 300 mg per dose every 1 to 3 days as tolerated
›Typical target 900 to 1800 mg per day
›Renal dose adjustment required
›Pregabalin 75 mg PO twice daily
›Titrate to 150 mg PO twice daily within 1 week as needed
›Renal dose adjustment required
›Amitriptyline 10 to 25 mg PO nightly
›Avoid in older adults when possible
›Anticholinergic adverse effects
›Opioid rescue for severe acute pain
›Short course only
›Avoid long duration use
›Reassess within 48 to 72 hours
›Oxycodone 5 mg PO every 6 hours as needed
›Avoid with significant respiratory risk
›Combine with bowel regimen if used
Topical therapy and skin care
›Local measures
›Cool wet compresses
›Itch reduction
›Lesion drying
›Calamine lotion
›Symptomatic itch relief
›Avoid near eyes
›Topical anesthetic for localized pain
›Lidocaine 5% patch
›Apply up to 12 hours on within 24 hours
›Avoid on open vesicles
›Corticosteroids
›Not routine for uncomplicated zoster
›Limited evidence for long term PHN prevention
›Risk in diabetes and immunosuppression
›Consider only with specialist input for severe inflammatory complications
›Ophthalmic uveitis
›CNS vasculopathy
›Antibiotics only if bacterial superinfection
›Cephalexin 500 mg PO four times daily for 5 to 7 days
›Cellulitis pattern
›Purulence absent
›Add MRSA coverage if risk factors
›Prior MRSA
›Purulent lesions
›Herpes zoster ophthalmicus
›Immediate systemic antiviral therapy
›Start without delay for ophthalmology
›Prefer valacyclovir or famciclovir
›Topical ophthalmic therapy only under ophthalmology guidance
›Avoid topical steroids without specialist
›Avoid topical anesthetics outpatient
›Ramsay Hunt syndrome
›Systemic antiviral plus steroid early if specialist agrees
›Higher risk of persistent facial weakness
›ENT follow up