What is the treatment for periorbital shingles?

Treatment of Periorbital Shingles

High-dose intravenous acyclovir is the treatment of choice for periorbital shingles due to the high risk of ocular complications. 1

Immediate Management

• First-line treatment:

  • IV acyclovir 5-10 mg/kg every 8 hours for 5-7 days or until clinical resolution 1
  • Treatment should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of rash onset 2

• Alternative oral options (for mild cases or to complete therapy after clinical response to IV treatment):

  • Valacyclovir 1 gram 3 times daily for 7 days 2
  • Famciclovir 500 mg every 8 hours for 7 days 3

Special Considerations for Periorbital Involvement

1. Ophthalmology consultation:

   • Immediate referral to ophthalmologist is essential for thorough evaluation including slit-lamp examination 1
   • Periorbital shingles may lead to serious ocular complications including keratitis, iridocyclitis, secondary glaucoma, and vision loss 4

2. Pain management:

   • Acute neuritis requires aggressive pain control with analgesics
   • Consider adding tricyclic antidepressants (e.g., amitriptyline) for neuropathic pain 4
   • Opioids may be necessary for severe pain 5

3. Adjunctive therapy:

   • Consider adding oral corticosteroids to antiviral medication to alleviate short-term zoster pain in immunocompetent patients 5
   • Caution: corticosteroids carry increased risk of serious adverse effects, especially in older adults 5

Dosage Adjustments for Renal Impairment

For patients with renal impairment, adjust dosing based on creatinine clearance:

Creatinine Clearance (mL/min)	Valacyclovir Dosing
≥50 (normal)	No adjustment needed
30-49	No adjustment needed
10-29	500 mg every 24 hours
<10	500 mg every 24 hours

2

Prevention of Complications

1. Postherpetic neuralgia (PHN) prevention:

   • Early aggressive antiviral therapy reduces risk 6
   • Consider adding analgesics early in treatment to prevent central sensitization 6

2. Infection control measures:

   • Patients with active periorbital shingles can transmit VZV to susceptible individuals 4
   • Advise avoiding contact with immunocompromised individuals, pregnant women, and those without history of chickenpox until lesions are crusted

Treatment Duration and Follow-up

• Continue antiviral therapy until all lesions have crusted over
• For immunocompromised patients, treatment duration may need to be extended (up to 14 days) as lesions develop over a longer period and heal more slowly 1
• Follow-up within 3-7 days to assess response to therapy
• Monitor for development of ocular complications requiring additional intervention

Special Patient Populations

1. Immunocompromised patients:

   • Higher risk of disseminated disease and complications
   • May require longer treatment duration
   • Consider hospitalization for severe cases or if compliance with oral therapy is questionable

2. HIV-infected patients:

   • May present with more severe disease and involvement of multiple dermatomes
   • Higher risk of recurrence
   • Consider suppressive therapy with oral antivirals after acute episode resolves 1

3. Pregnant patients:

   • Acyclovir is preferred due to more extensive safety data 7
   • Consult with obstetrician regarding potential risks

Warning Signs Requiring Urgent Care

• Visual changes or eye pain
• Severe or worsening pain despite treatment
• Signs of bacterial superinfection (increased redness, swelling, purulent discharge)
• Dissemination of lesions beyond the initial dermatome
• Neurological symptoms beyond the affected dermatome

Periorbital shingles represents a medical emergency due to the risk of vision-threatening complications. Early and aggressive treatment with intravenous antivirals, coupled with ophthalmologic evaluation, is essential to prevent serious sequelae.