What is the recommended treatment for patients with periorbital cellulitis linked to herpes zoster ophthalmicus (HZO)?

Treatment for Periorbital Cellulitis Linked to Herpes Zoster Ophthalmicus

For periorbital cellulitis associated with herpes zoster ophthalmicus (HZO), the recommended treatment is oral antiviral therapy (valacyclovir 1000 mg three times daily for 7 days) combined with topical antibiotics to prevent secondary bacterial infection. 1

Antiviral Therapy

• Oral antivirals are the mainstay of treatment for HZO with periorbital involvement and should be started as soon as possible, ideally within 72 hours of rash onset 2, 3

• Recommended oral antiviral regimens for immunocompetent adults with HZO-related periorbital cellulitis:

  • Valacyclovir: 1000 mg every 8 hours for 7 days (preferred due to better bioavailability) 1, 4
  • Acyclovir: 800 mg five times daily for 7 days 1
  • Famciclovir: 500 mg three times daily for 7 days 1

• Patients with chronic or recalcitrant disease may require prolonged treatment with dose adjustments based on clinical response 1

• Immunocompromised patients may need more aggressive antiviral therapy 1

Prevention of Secondary Bacterial Infection

• Topical antibiotics are recommended to prevent secondary bacterial infection of vesicles that undergo necrosis before healing 1
• Secondary bacterial infection can lead to severe complications including cicatricial ectropion 1
• The choice of topical antibiotic should cover common skin pathogens 5

Role of Topical Antivirals

• Topical antivirals alone have not been shown to be helpful in treating VZV conjunctivitis 1
• They may be used as additive treatment in unresponsive patients 1
• If used, options include:
  • Ganciclovir 0.15% gel (less toxic to ocular surface) 1
  • Trifluridine 1% solution (note: causes epithelial toxicity if used >2 weeks) 1

Special Considerations

• Caution is advised when using systemic antiviral therapy in patients with impaired renal clearance; dose adjustments may be necessary 1, 4
• Topical corticosteroids should be avoided in epithelial viral infections as they can potentiate the infection 1
• Monitor for potential ocular complications of HZO, which may include:
  • Pseudodendrites, keratitis, corneal scarring 1, 6
  • Corneal vascularization, iritis/uveitis 1, 6
  • Sectoral iris atrophy and secondary glaucoma 1

Follow-up Recommendations

• Patients should have a follow-up visit within 1 week of treatment initiation 1
• The follow-up should include:
  • Interval history 1
  • Visual acuity measurement 1
  • Slit-lamp biomicroscopy 1
• Ophthalmology consultation is recommended when ocular involvement is present to limit visual morbidity 2, 7

Common Pitfalls

• Delayed diagnosis: HZO can sometimes masquerade as orbital cellulitis, leading to delayed appropriate treatment 5
• Late sequelae of HZO may include dry eye and corneal anesthesia with neurotrophic keratitis, requiring ongoing monitoring 1
• Failure to recognize and treat HZO promptly (within 72 hours) increases the risk of ocular complications 2, 3