Should a patient with herpetic vesicles on the external auditory meatus be started on valacyclovir (valacyclovir) or referred to ophthalmology?

Management of Herpetic Vesicles on the External Auditory Meatus

Patients with herpetic vesicles on the external auditory meatus should be started on valacyclovir AND referred to ophthalmology due to the risk of ocular complications.

Initial Management

Antiviral Therapy

• Start valacyclovir immediately:
  • Dosage: 1000 mg three times daily for 7 days 1, 2
  • Alternative options if valacyclovir is unavailable:
    • Acyclovir 800 mg five times daily for 7-10 days 2
    • Famciclovir 500 mg three times daily for 7 days 1

Specialist Referral

• Urgent ophthalmology referral is essential due to:
  • Proximity to ocular structures
  • Risk of VZV conjunctivitis progressing to keratitis, corneal scarring, uveitis, and secondary glaucoma 1
  • Potential for corneal anesthesia with neurotrophic keratitis as a late sequela 1

Rationale for Dual Approach

Why Start Antiviral Therapy Immediately

• Early initiation (within 72 hours of onset) maximizes effectiveness 2
• Reduces viral replication and shedding
• Decreases severity and duration of symptoms 3
• Reduces risk of postherpetic neuralgia 3
• Limits potential spread to ocular structures

Why Ophthalmology Referral is Critical

• Herpetic infections in the external auditory meatus can:
  • Spread to adjacent structures including the eye
  • Lead to serious ocular complications requiring specialized management 1
  • Result in pseudodendrites, keratitis, corneal scarring, corneal vascularization, iritis/uveitis, sectoral iris atrophy, and secondary glaucoma 1

Follow-up Recommendations

• Schedule follow-up within 7 days to:
  • Assess treatment response
  • Monitor for complete resolution of lesions
  • Evaluate for signs of dissemination or complications 2
  • Ensure ophthalmology evaluation has occurred

Special Considerations

• Immunocompromised patients may need more aggressive treatment and closer monitoring 2
• Pain management may be necessary:
  • For mild pain: acetaminophen or NSAIDs
  • For moderate to severe pain: consider gabapentin or pregabalin 2
  • For localized pain: lidocaine patches may be beneficial 2

Pitfalls to Avoid

• Delay in treatment initiation: Starting antivirals after 72 hours significantly reduces effectiveness 4
• Using topical antivirals alone: Topical antivirals have not been shown to be helpful in treating VZV conjunctivitis when used alone 1
• Prescribing topical corticosteroids: These can potentiate HSV infections and should be avoided without concurrent antiviral therapy 1
• Failing to adjust dosage for patients with renal impairment 2
• Missing follow-up: Complications can develop even after initial improvement

By combining immediate antiviral therapy with specialist ophthalmology referral, you provide the best chance for preventing serious complications while effectively treating the acute infection.