Cosmetic Complications of Herpes Zoster
Scarring after herpes zoster occurs in approximately 10% of patients at 6 months, with the principal risk factors being severe disease and immunosuppression—both of which apply to your patient over 50 with compromised immunity. 1
Types of Cosmetic Scarring
The specific cosmetic complications depend on skin type and disease severity:
In fair-skinned patients, post-HZ scarring manifests as:
- Hypopigmented scars 1
- Hyperpigmented scars 1
- Atrophic cicatricial (depressed) scars 1
- Hypertrophic cicatricial (raised) scars 1
In dark-skinned patients, the predominant pattern is:
- Severe hyperpigmented hypertrophic scarring 1
In severe cases, particularly immunocompromised patients, necrodestructive lesions can cause:
- Mutilating scarring with tissue destruction 2
- Complete obstruction of anatomical structures (such as nasal passages when facial involvement occurs) 2
High-Risk Features for Scarring
Your patient's profile places them at elevated risk based on these factors:
- Age over 50: Increased baseline risk for severe disease 3
- Immunocompromised status: 9 of 11 patients with persistent scarring at 6 months were immunocompromised 1
- Extensive and severe HZ: All patients with persistent scarring had extensive, severe disease 1
Anatomical Distribution of Scarring Risk
The most frequent locations for post-HZ scarring are:
- Trunk (45% of scarring cases) 1
- Cervical region (27% of scarring cases) 1
- Face (27% of scarring cases) 1
Facial involvement carries particular cosmetic concern, as ophthalmic division involvement can result in prolonged facial scarring and severe itch 4, and nasal involvement can cause disfiguring tissue destruction 2.
Prevention Strategy
The most critical intervention to reduce cosmetic complications is prompt antiviral therapy within 72 hours of rash onset, as this decreases the severity and duration of disease 5, 4.
For your immunocompromised patient over 50:
- Intravenous acyclovir is recommended for disseminated or invasive herpes zoster 5
- Consider temporary reduction in immunosuppressive medication if disseminated disease develops 5
- Continue treatment until all lesions have completely scabbed, not just an arbitrary 7-day period 5
Additional Cosmetic Considerations
Beyond scarring, other cosmetic sequelae include:
- Post-inflammatory hyperpigmentation or depigmentation, which can persist long-term 2
- Facial nerve palsies causing asymmetry (cranial nerve involvement) 3
- Ophthalmic complications potentially affecting periorbital appearance 4
Vaccination for Future Prevention
After recovery, the recombinant zoster vaccine (Shingrix) should be considered to prevent future episodes, as it is not contraindicated in immunocompromised patients unlike the live vaccine 3, 5. This is particularly important since your patient has already demonstrated susceptibility to severe disease.