What is the recommended treatment for a 73-year-old male with shingles (herpes zoster) of the face?

Treatment of Facial Herpes Zoster in a 73-Year-Old Male

Oral valacyclovir 1 gram three times daily for 7 days is the recommended first-line treatment for facial herpes zoster in a 73-year-old male, and should be initiated as soon as possible after diagnosis. 1, 2

First-Line Antiviral Therapy

• Valacyclovir 1 gram three times daily for 7 days is the recommended treatment for herpes zoster in adults 2
• Treatment 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 2
• Valacyclovir has better bioavailability than acyclovir, allowing for less frequent dosing and improved adherence 3
• For facial zoster, prompt treatment is particularly important due to the risk of complications including ocular involvement 1

Alternative Antiviral Options

• If valacyclovir is unavailable, oral acyclovir 800 mg 5 times daily for 7 days can be used 1, 3
• Famciclovir is another alternative with similar efficacy to valacyclovir 3, 4
• Intravenous acyclovir should be considered if the patient has disseminated or invasive disease, or is severely immunocompromised 1

Special Considerations for Facial Zoster

• Facial zoster requires careful evaluation for potential ophthalmic involvement (herpes zoster ophthalmicus) 5
• If there is any suspicion of eye involvement (rash on the tip or side of nose, or any ocular symptoms), urgent ophthalmology consultation is recommended 5
• Monitor for neurological complications, which are more common with facial zoster 6
• Consider temporary reduction in any immunosuppressive medications if the patient is on them 1

Adjunctive Therapies

• Pain management is essential - consider acetaminophen or NSAIDs for mild pain 4
• For moderate to severe pain, stronger analgesics may be necessary 4
• Topical antiviral therapy is substantially less effective than systemic therapy and is not recommended 1
• While some clinicians use corticosteroids to reduce inflammation and pain, evidence shows only modest benefits and potential risks, especially in older adults 7

Monitoring and Follow-up

• Monitor until all lesions have scabbed over, which typically takes 2-3 weeks 1
• Watch for secondary bacterial infection of lesions, which may require antibiotics 6
• Follow up for development of post-herpetic neuralgia, which is more common in older adults 3
• If post-herpetic neuralgia develops, consider tricyclic antidepressants, gabapentin, pregabalin, or topical agents like lidocaine or capsaicin 4

Prevention of Future Episodes

• Consider recommending recombinant zoster vaccine (Shingrix) after recovery to prevent future episodes 8
• The recombinant zoster vaccine is recommended for adults aged 50 years and older regardless of prior episodes of herpes zoster 8
• Vaccination has been shown to reduce the incidence of herpes zoster and post-herpetic neuralgia 4

Common Pitfalls to Avoid

• Delaying treatment beyond 72 hours reduces effectiveness, though some benefit may still be seen with later initiation 3
• Inadequate pain management can lead to decreased quality of life and increased risk of post-herpetic neuralgia 4
• Failure to recognize ophthalmic involvement can lead to serious complications including vision loss 5
• Underestimating the importance of adherence to the full 7-day course of antiviral therapy 2