What are the symptoms, signs, complications, progression, and treatment of trigeminal herpes zoster, including abortive treatment?

Trigeminal Herpes Zoster: Symptoms, Signs, Complications, and Progression

Trigeminal herpes zoster is characterized by painful vesicular eruptions along one or more branches of the trigeminal nerve, requiring prompt antiviral therapy to prevent serious complications including postherpetic neuralgia and ocular damage. Early recognition and treatment are essential for reducing morbidity and improving quality of life outcomes.

Clinical Presentation and Symptoms

Prodromal Phase

• Pain, erythema, and tenderness in the affected trigeminal dermatome, typically occurring 2-4 days before rash appearance
• May present as odontalgia (tooth pain), which can be a diagnostic challenge 1
• Headache, malaise, and occasionally low-grade fever
• In some cases, facial and neck pain may mimic carotid artery dissection 2

Active Phase

• Characteristic progression of skin lesions:
  • Initial erythematous maculopapular rash
  • Evolution to clear vesicles within hours
  • Pustulation within 2-4 days
  • Crusting within 7-10 days 3
• Lesions strictly follow the affected trigeminal branch distribution
• Severe neuralgic pain described as burning, shooting, or electric shock-like
• Lesions typically last 2-3 weeks if uncomplicated 3

Distribution by Trigeminal Division

1. First division (ophthalmic): Most commonly affected branch

   • Forehead, upper eyelid, and tip of nose
   • Hutchinson's sign: Vesicles on the tip or side of nose indicate nasociliary nerve involvement and higher risk of ocular complications 4

2. Second division (maxillary): Less commonly affected

   • Cheek, upper lip, upper teeth, and palate

3. Third division (mandibular): Rarely affected

   • Lower lip, chin, lower teeth, and tongue 1

Complications

Neurological Complications

• Postherpetic neuralgia (PHN): Most debilitating complication
  • Persistent pain lasting >3 months after rash healing
  • Higher risk in elderly and immunocompromised patients 3
• Cranial nerve palsies (particularly abducens nerve)
• Motor weakness in the affected area 5

Ocular Complications (Herpes Zoster Ophthalmicus)

• Conjunctivitis
• Keratitis
• Uveitis
• Scleritis
• Retinal necrosis (acute retinal necrosis or progressive outer retinal necrosis)
• Secondary glaucoma
• Optic neuritis
• Severe bilateral photophobia even without visible inflammation 5
• Ocular complications may develop despite antiviral treatment 6

Other Complications

• Secondary bacterial infection of skin lesions
• Scarring
• Hyperpigmentation
• Disseminated zoster (in immunocompromised patients)
• Visceral involvement (rare)

Disease Progression

1. Virus reactivation: VZV reactivates from latency in the trigeminal ganglion
2. Prodromal phase: Pain and sensory symptoms (2-4 days)
3. Acute phase: Vesicular eruption and peak pain (7-10 days)
4. Resolution phase: Crusting and healing (2-3 weeks)
5. Post-herpetic phase: Potential development of PHN (>3 months)

Abortive Trigeminal Herpes Zoster

Abortive herpes zoster refers to a form of the disease where:

• Prodromal symptoms and pain occur in a dermatomal distribution
• Limited or absent cutaneous manifestations (vesicles may be minimal or absent)
• Diagnosis is challenging due to lack of characteristic rash
• May present with only neurological symptoms like photophobia or nerve palsy 5
• Can still lead to complications including PHN despite minimal skin findings

Management Approach

Antiviral Therapy

• Start within 72 hours of rash onset for maximum effectiveness 6
• Options include:
  • Acyclovir: 800 mg five times daily for 7 days
  • Valacyclovir: 1000 mg three times daily for 7 days
  • Famciclovir: 500 mg three times daily for 7 days 3

Pain Management

• Analgesics: NSAIDs, acetaminophen
• Neuropathic pain medications: Gabapentin, pregabalin, tricyclic antidepressants
• Opioids for severe pain if needed

Adjunctive Therapy

• Corticosteroids may be beneficial, especially for neurological complications
  • Particularly important when neurological symptoms persist despite antiviral therapy 5
• Topical antibiotics if secondary bacterial infection occurs

Prevention

• Vaccination with recombinant zoster vaccine (Shingrix) is highly effective
  • Recommended for adults ≥50 years and immunocompromised adults ≥18 years 3

Clinical Pearls and Pitfalls

• Early diagnosis is crucial: Treatment within 72 hours of rash onset significantly reduces complications
• Hutchinson's sign: Vesicles on the tip of nose strongly predict ocular involvement
• Don't miss abortive zoster: Consider in patients with unexplained unilateral facial pain even without rash
• Watch for ocular involvement: Prompt ophthalmology referral for any eye symptoms
• Bilateral symptoms can occur: Despite unilateral rash, symptoms like photophobia may be bilateral 5
• Consider immune status: Immunocompromised patients have higher risk of dissemination and complications
• Long-term follow-up: Monitor for development of PHN and other neurological sequelae

Careful attention to the distribution of pain and rash along trigeminal nerve branches helps distinguish herpes zoster from other causes of facial pain and ensures appropriate treatment is initiated promptly.