What is the treatment for shingles (herpes zoster) affecting the nose and eye?

Treatment for Shingles Affecting the Nose and Eye

Immediate treatment with oral antiviral therapy (valacyclovir 1 gram three times daily for 7 days) is essential for herpes zoster affecting the nose and eye to prevent serious ocular complications and reduce the risk of postherpetic neuralgia. 1

Diagnosis and Significance

• Herpes zoster (shingles) affecting the nose and eye represents herpes zoster ophthalmicus, which occurs in 10-20% of all shingles cases 2
• The presence of vesicular lesions on the tip or side of the nose (Hutchinson's sign) indicates involvement of the nasociliary branch of the trigeminal nerve and significantly increases the risk of ocular complications 3
• Approximately 50% of patients with herpes zoster ophthalmicus will develop ocular manifestations, making this an ophthalmic emergency requiring prompt treatment 2

Treatment Algorithm

1. Antiviral Therapy (First Line)

• Start immediately (ideally within 72 hours of rash onset) with one of the following:
  • Valacyclovir 1 gram three times daily for 7 days (preferred due to better bioavailability) 1
  • Alternatively: Acyclovir 800 mg five times daily for 7-10 days 4
• Early antiviral therapy is critical for reducing the severity and duration of acute pain, preventing ocular complications, and reducing the risk of postherpetic neuralgia 5

2. Ocular Management

• Daily ophthalmological review is necessary during the acute illness 6
• Apply non-preserved ocular lubricants (e.g., hyaluronate or carmellose eye drops) every 2 hours throughout the acute illness 6
• Ocular hygiene must be performed daily by an ophthalmologist or ophthalmically trained nurse 6
• Consider topical corticosteroid drops (e.g., non-preserved dexamethasone 0.1% twice daily) to reduce ocular surface damage 6
• Administer broad-spectrum topical antibiotics (e.g., moxifloxacin drops four times daily) if corneal fluorescein staining or ulceration is present 6

3. Pain Management

• Use appropriate analgesics to ensure comfort at rest 6
• Additional pain control may be achieved by supplementing antiviral agents with:
  • Oral corticosteroids (in selected patients without contraindications)
  • Analgesics (including opioids if necessary for severe pain)
  • For persistent pain (postherpetic neuralgia), consider tricyclic antidepressants or anticonvulsants in low doses 5

Special Considerations

• Ocular complications can include keratitis, uveitis, scleritis, retinitis, and optic neuritis, which may lead to permanent vision loss if not promptly treated 7
• Patients with herpes zoster ophthalmicus should be monitored for delayed complications, including contralateral hemiparesis, which can present as stroke 7
• Immunocompromised patients are at higher risk for disseminated disease and may require more aggressive treatment, possibly including intravenous antivirals 6

Prevention

• Recombinant zoster vaccine (RZV) is recommended for prevention of herpes zoster and related complications in:
  • Immunocompetent adults aged 50 years or older 6
  • Immunocompromised patients 19 years and older 6
  • Adults who previously received the older zoster vaccine live (ZVL) 6
• RZV is preferred over ZVL due to higher efficacy (96% vs. 70%) 6

Common Pitfalls to Avoid

• Delayed treatment: Initiating antiviral therapy more than 72 hours after rash onset significantly reduces effectiveness 1
• Missing ocular involvement: Always suspect ocular involvement when vesicles appear on the nose (Hutchinson's sign) 3
• Inadequate follow-up: Patients with herpes zoster ophthalmicus require close monitoring for development of complications, even after the acute phase has resolved 2
• Underestimating pain: Postherpetic neuralgia can be severely debilitating and may require multimodal pain management strategies 5