From the Research
For mild persistent asthma in a patient with ocular herpes, inhaled corticosteroids (ICS) at low doses are recommended as the preferred controller medication, while avoiding systemic corticosteroids whenever possible. Specific options include low-dose fluticasone (88-220 mcg/day), beclomethasone (80-240 mcg/day), or budesonide (180-540 mcg/day) via metered-dose inhaler. A short-acting beta-agonist like albuterol should be prescribed as needed for symptom relief. Leukotriene modifiers such as montelukast (10 mg daily for adults) can be considered as alternative controller medications. The concern with ocular herpes is that systemic corticosteroids may trigger reactivation or worsening of herpes infection, so they should be avoided if possible 1. If an asthma exacerbation occurs requiring systemic steroids, close monitoring for herpes reactivation is necessary, and prophylactic antiviral therapy (such as acyclovir 400 mg twice daily) might be considered during the steroid course. Regular follow-up is important to ensure asthma control while monitoring for any signs of herpes reactivation. The use of single maintenance and reliever therapy compared with inhaled corticosteroids as the controller therapy (with or without a long-acting β-agonist) and short-acting β-agonists as the relief therapy was associated with a lower risk of asthma exacerbations 2. However, the primary concern in this case is the management of mild persistent asthma in the context of ocular herpes, and thus the focus remains on the use of inhaled corticosteroids at low doses and the avoidance of systemic corticosteroids. In terms of the safety of inhaled corticosteroids, they have been found to have minimal systemic effects in most patients when taken at recommended doses 3. Ocular effects of ICSs and ICS effects on bone mineral density and adrenal function are minimal in patients maintained on recommended ICS doses. Therefore, the benefits of ICS therapy clearly outweigh the risks of uncontrolled asthma, and ICSs should be prescribed routinely as first-line therapy for children and adults with persistent disease. It is also important to note that while there are potential complications of inhaled steroid therapy, such as the case report of a concomitant Candida and Herpes simplex oesophagitis occurring in a steroid-dependent asthmatic who had been maintained on inhaled beclomethasone 4, these are rare and should not preclude the use of inhaled corticosteroids in patients with mild persistent asthma and ocular herpes. Overall, the management of mild persistent asthma in a patient with ocular herpes should prioritize the use of inhaled corticosteroids at low doses, avoidance of systemic corticosteroids, and close monitoring for any signs of herpes reactivation.