What is the treatment for a patient presenting with a herpes zoster (shingles) rash on the right side of their face and dried blood in the right ear, with obscured tympanic membrane (eardrum) visibility?

From the Guidelines

For a patient presenting with a suspected shingles rash on the right side of the face and dried blood in the right ear, immediate medical attention is necessary, and antiviral therapy should be started promptly with valacyclovir 1000mg three times daily for 7 days. The patient's presentation is concerning for Ramsay Hunt syndrome (herpes zoster oticus), which involves the facial nerve and can cause facial paralysis, hearing loss, and vertigo 1. Early treatment within 72 hours of rash onset is crucial to reduce complications like postherpetic neuralgia and potential permanent facial nerve damage. The ear canal should be gently cleaned by a healthcare professional to remove dried blood and allow proper examination of the tympanic membrane. Pain management with acetaminophen or NSAIDs for mild pain, or consider gabapentin starting at 300mg daily and titrating up as needed for more severe pain, is also recommended. The patient should be referred to an otolaryngologist or neurologist for specialized care, especially if facial weakness is present. Shingles on the face requires aggressive treatment due to the risk of eye involvement and potential complications affecting cranial nerves. It is also important to consider the possibility of other conditions, such as necrotizing otitis externa or otomycosis, especially in immunocompromised patients, and to adjust treatment accordingly 1. However, the primary concern in this case is the treatment of the shingles rash and the potential complications associated with it. The use of antiviral therapy, such as valacyclovir, is supported by the most recent and highest quality study, and it is the recommended treatment for patients with shingles, especially when presented with a high risk of complications 1.

From the FDA Drug Label

The recommended dosage of VALTREX for treatment of herpes zoster is 1 gram 3 times daily for 7 days Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of the onset of rash.

The treatment for a patient presenting with a herpes zoster (shingles) rash on the right side of their face and dried blood in the right ear, with obscured tympanic membrane (eardrum) visibility is valacyclovir 1 gram 3 times daily for 7 days. Therapy should be initiated as soon as possible, ideally within 48 hours of the onset of the rash 2.

• Key considerations:
  • Initiate treatment at the earliest sign or symptom of herpes zoster
  • Most effective when started within 48 hours of the onset of rash
  • Dosage: 1 gram 3 times daily for 7 days

From the Research

Treatment for Herpes Zoster

The patient presenting with a herpes zoster (shingles) rash on the right side of their face and dried blood in the right ear, with obscured tympanic membrane (eardrum) visibility, requires prompt treatment.

• The treatment options for herpes zoster include antiviral medications such as valaciclovir, acyclovir, and famciclovir 3, 4, 5.
• Valaciclovir has been shown to be at least as effective as acyclovir in controlling the symptoms of acute herpes zoster and alleviating zoster-associated pain and postherpetic neuralgia 3, 5.
• The recommended regimen for valaciclovir is 1000 mg three times daily for 7 days 3, 5, although a twice-daily dosing schedule of 1.5 g has also been shown to be safe and effective 6.
• Treatment with antivirals is most effective when initiated within the first 72 hours of the onset of the rash 4, 6.
• In addition to antiviral medications, other treatment options for postherpetic neuralgia, a potential complication of herpes zoster, include topical analgesics, opioid analgesics, tricyclic antidepressants, and gabapentin 4.
• However, the use of low-dose gabapentin in acute herpes zoster has been shown to be ineffective in preventing postherpetic neuralgia 7.

Considerations for the Patient's Condition

• The patient's symptoms, including the rash on the right side of their face and dried blood in the right ear, suggest a possible complication of herpes zoster, such as zoster ophthalmicus or involvement of the ear.
• The obscured tympanic membrane visibility may indicate a need for further evaluation and treatment by an ear, nose, and throat (ENT) specialist or an ophthalmologist, depending on the extent of the involvement.
• The patient's treatment plan should be individualized based on the severity of their symptoms, their medical history, and their response to treatment 3, 4, 5, 6.