Is numbness on the face and eye discomfort normal with a cold sore (herpes simplex virus) infection?

Facial Numbness and Eye Discomfort with Cold Sores: Evaluation and Management

Yes, facial numbness and eye discomfort can occur with herpes simplex virus (HSV) cold sores and may indicate nerve involvement that requires prompt medical attention.

Understanding HSV and Neurological Symptoms

• HSV-1 is the primary cause of herpes labialis (cold sores), which typically manifests as painful vesicular lesions on or around the lips 1
• When HSV affects the trigeminal nerve, it can cause sensory disturbances including numbness and paresthesia in the distribution of the affected nerve branch 1
• Neurological symptoms like facial numbness may occur during both primary infection and recurrent episodes due to viral replication in sensory nerve ganglia 2

Clinical Significance of Eye Discomfort with Cold Sores

• Eye discomfort accompanying cold sores warrants immediate attention as it may indicate:

  • HSV keratitis or conjunctivitis, which can lead to serious complications if untreated 1
  • Potential involvement of the ophthalmic branch of the trigeminal nerve 3
  • Risk of corneal scarring, decreased vision, or other ocular complications 1

• HSV ocular involvement typically presents with:

  • Unilateral symptoms (though can be bilateral, especially in immunocompromised patients) 1
  • Bulbar conjunctival injection (redness) 1
  • Watery discharge 1
  • Potential for corneal involvement with epithelial keratitis 1

Evaluation Algorithm

1. Assess for warning signs requiring urgent care:

   • Visual changes or decreased acuity 1
   • Severe eye pain or photophobia 4
   • Vesicular rash extending to the tip of the nose (Hutchinson's sign) suggesting ophthalmic nerve involvement 1
   • Focal neurological deficits beyond simple numbness 3

2. Determine if symptoms suggest simple HSV reactivation or complications:

   • Mild, transient numbness limited to the area around the cold sore is often benign 1
   • Extensive, persistent, or spreading numbness may indicate more significant neurological involvement 3
   • Eye discomfort with redness, tearing, or light sensitivity suggests ocular involvement 1

Management Recommendations

For Cold Sores with Mild Facial Numbness (No Eye Involvement)

• Oral antiviral therapy is recommended to reduce duration and severity:

  • Acyclovir (200-400 mg five times daily) 1
  • Valacyclovir (500 mg two to three times daily) 4
  • Famciclovir (250 mg twice daily) 1

• Treatment duration should be 7-10 days for acute episodes 4

For Cold Sores with Eye Discomfort

• Urgent ophthalmologic evaluation is necessary to rule out HSV keratitis or other ocular complications 1

• Treatment typically includes:

  • Oral antiviral therapy at therapeutic doses (valacyclovir 500 mg three times daily) 4
  • Possible addition of topical antiviral treatment if corneal involvement is confirmed:
    • Ganciclovir 0.15% gel three to five times daily (preferred due to lower ocular surface toxicity) 1
    • Trifluridine 1% solution five to eight times daily (limited to short-term use due to epithelial toxicity) 1

• Avoid topical corticosteroids unless specifically prescribed by an ophthalmologist, as they can potentiate HSV infection 1

When to Seek Immediate Medical Attention

• Facial numbness extending beyond the immediate area of the cold sore 3
• Any eye symptoms including redness, pain, discharge, or vision changes 1
• Symptoms persisting beyond 7-10 days despite treatment 1
• Immunocompromised status with any HSV symptoms 1

Follow-up Recommendations

• All patients with eye involvement should have follow-up within one week of treatment initiation 4
• Assessment should include visual acuity measurement and slit-lamp biomicroscopy 1
• Patients with persistent neurological symptoms should be evaluated for potential complications such as postherpetic neuralgia 3