Treatment for Shingles of the Face
For facial shingles, especially when the eye is involved (herpes zoster ophthalmicus), start valacyclovir 1000 mg three times daily for 7 days immediately and refer urgently to an ophthalmologist. 1, 2
First-Line Antiviral Therapy
Valacyclovir is the preferred oral antiviral due to superior bioavailability and simpler dosing compared to acyclovir 1, 2, 3:
- Valacyclovir 1000 mg three times daily for 7 days 1, 3
- Alternative: Acyclovir 800 mg five times daily for 7 days 1, 3
- Alternative: Famciclovir 500 mg three times daily for 7 days 1, 4
Initiate treatment immediately - ideally within 48-72 hours of rash onset, though treatment may still be beneficial even after 72 hours 3, 5. The antiviral therapy accelerates resolution of pain, reduces postherpetic neuralgia risk, and prevents ocular complications 6, 7.
Mandatory Ophthalmology Referral
Immediate involvement of an experienced ophthalmologist is strongly recommended for all cases of facial shingles near or involving the eye 1, 2. This is critical because herpes zoster ophthalmicus can cause serious complications including:
- Pseudodendrites and keratitis 1
- Corneal scarring and vascularization 1
- Uveitis and sectoral iris atrophy 1
- Secondary glaucoma 1
- Neurotrophic keratitis from corneal anesthesia 1, 8
Adjunctive Therapy
Apply topical antibiotics to vesicles to prevent secondary bacterial infection that can lead to severe complications including cicatricial ectropion 8, 2.
Avoid topical corticosteroids during active epithelial viral infection as they can potentiate the infection 8, 2. However, for inflammatory complications without epithelial disease (such as subepithelial infiltrates causing vision problems), topical corticosteroids at minimum effective dose may be considered under ophthalmologist supervision 8.
Topical antivirals alone are not helpful for VZV conjunctivitis, but ganciclovir 0.15% gel or trifluridine 1% solution may be used as additive treatment in unresponsive patients 8, 2.
Pain Management
Appropriately dosed analgesics combined with neuroactive agents (such as amitriptyline) should be given together with antiviral therapy to achieve painlessness 9. Valacyclovir significantly accelerates resolution of zoster-associated pain compared to acyclovir (median 38 days versus 51 days) and reduces postherpetic neuralgia incidence (19.3% versus 25.7%) 6.
Special Populations
Immunocompromised patients require more aggressive antiviral therapy with potential dose adjustments based on clinical response 10, 8, 2. High-dose IV acyclovir remains the treatment of choice for VZV infections in severely compromised hosts 10.
Adjust dosing for renal impairment - patients with creatinine clearance <50 mL/min require dose reduction 3. Exercise caution with systemic antiviral therapy in patients with impaired renal clearance 8.
Follow-Up Protocol
Schedule follow-up within 1 week of treatment initiation, including 1, 8:
- Interval history
- Visual acuity measurement
- Slit-lamp biomicroscopy
- Assessment for resolution of acute symptoms
- Evaluation for development of complications
Monitor intraocular pressure if the patient is on corticosteroid therapy 8.
Common Pitfalls
Do not delay treatment waiting for ophthalmology consultation - start oral antivirals immediately while arranging urgent referral 1, 2.
Do not use topical antivirals as monotherapy - they do not reach the site of viral reactivation in the ganglia 10.
Monitor for late sequelae including dry eye and neurotrophic keratitis, which may develop months after the acute infection 1, 8.
Prolonged treatment may be necessary for chronic or recalcitrant disease, with dose adjustments based on clinical response 1, 8.