Management of Facial Shingles (Herpes Zoster)
For facial herpes zoster, initiate oral valacyclovir 1 gram three times daily for 7 days as soon as possible, ideally within 72 hours of rash onset, and continue treatment until all lesions have scabbed. 1, 2, 3
Antiviral Treatment Algorithm
First-Line Oral Therapy (Uncomplicated Cases)
- Valacyclovir 1 gram orally three times daily for 7 days is the preferred first-line treatment 1, 2, 3
- Alternative option: Acyclovir 800 mg orally five times daily for 7 days 1, 2
- Alternative option: Famciclovir 500 mg every 8 hours for 7 days 2, 4
- Treatment should be initiated within 72 hours of rash onset for optimal efficacy, though benefit may still occur with later initiation 1, 5
- Continue treatment until all lesions have scabbed, which may require extending beyond 7 days in some cases 1, 2
Intravenous Therapy (Severe/Complicated Cases)
- Intravenous acyclovir 5-10 mg/kg every 8 hours is indicated for: 6, 1, 2
- Disseminated herpes zoster
- Multi-dermatomal involvement
- Ophthalmic zoster with severe complications
- Immunocompromised patients with severe disease
- Visceral involvement
- Switch to oral therapy once clinical improvement occurs 2
- Continue IV treatment until clinical resolution is attained 2
Special Considerations for Facial Involvement
Ophthalmic Zoster
- Facial zoster requires particular attention due to risk of cranial nerve complications 1
- Ophthalmic involvement generally merits referral to an ophthalmologist 7
- Use the same antiviral regimens as for other facial zoster 5
Supportive Care Measures
- Elevate the affected area to promote drainage of edema and inflammatory substances 1
- Keep skin well hydrated with emollients to avoid dryness and cracking 1
- Consider topical analgesics for symptomatic relief, though these do not replace systemic antiviral therapy 6
Management in Immunocompromised Patients
- All immunocompromised patients require antiviral treatment regardless of timing 2
- Consider temporary reduction in immunosuppressive medications for disseminated or invasive disease 1, 2
- Immunosuppression may be restarted after commencing antiviral therapy and resolution of skin vesicles 2
- Monitor closely for dissemination and visceral complications 2
- Laboratory confirmation may be needed if clinical presentation is atypical 1
Dosing Adjustments for Renal Impairment
- Reduce valacyclovir dose based on creatinine clearance: 3
- CrCl 30-49 mL/min: 1 gram every 12 hours
- CrCl 10-29 mL/min: 1 gram every 24 hours
- CrCl <10 mL/min: 500 mg every 24 hours
- Similar dose adjustments apply to acyclovir and famciclovir 2, 4
Pain Management
- Acute pain control may require narcotics for adequate relief 7
- Tricyclic antidepressants or anticonvulsants in low doses can help control neuropathic pain 7
- Adjunctive corticosteroids (prednisone) may provide modest benefits in reducing acute pain in select cases of severe, widespread disease, but should be avoided in immunocompromised patients 1
- Capsaicin cream and lidocaine patches can be used for localized pain relief 7
Critical Pitfalls to Avoid
- Do not use topical antiviral therapy alone - it is substantially less effective than systemic therapy and is not recommended 1
- Do not delay treatment waiting for laboratory confirmation in typical presentations - initiate antivirals based on clinical diagnosis 1
- Do not stop treatment at 7 days if new lesions continue to form or healing is incomplete 2
- Do not use corticosteroids in immunocompromised patients due to increased risk of disseminated infection 1
Acyclovir-Resistant Cases
- For suspected acyclovir-resistant herpes zoster, foscarnet 40 mg/kg IV every 8 hours is recommended 2
- Acyclovir-resistant isolates are routinely resistant to ganciclovir as well 2