What is the treatment for a 50-year-old adult with no known immunocompromised status, presenting with shingles (herpes zoster) on the left face, forehead, and near the eye, but not in the eye?

Treatment for Facial Shingles Near the Eye

Initiate oral valacyclovir 1000 mg three times daily for 7-10 days immediately and arrange urgent ophthalmology evaluation within 24 hours, as this represents herpes zoster ophthalmicus (HZO) with high risk for vision-threatening complications. 1

Immediate Antiviral Therapy

The American Academy of Infectious Diseases recommends starting treatment within 48-72 hours of rash onset for optimal efficacy, though treatment should be initiated even if this window has passed. 1 For facial shingles in adults over 50, you have two equally effective first-line options:

• Valacyclovir 1000 mg three times daily for 7-10 days (preferred due to better bioavailability and less frequent dosing) 1, 2
• Acyclovir 800 mg five times daily for 7-10 days (requires more frequent dosing but equally effective) 1, 2

Continue treatment until all lesions have completely scabbed, not just for an arbitrary 7-day period—this is the key clinical endpoint. 1, 3 The FDA label confirms valacyclovir is indicated for herpes zoster treatment when initiated within 72 hours of rash onset. 2

Urgent Ophthalmology Referral

Any facial shingles involving the forehead, eyelid, or nose requires ophthalmology evaluation within 24 hours, even if the eye itself appears uninvolved. 1 This location indicates potential involvement of the nasociliary branch of the trigeminal nerve (Hutchinson's sign), which carries approximately 50% risk of ocular complications. 4, 5

Daily ophthalmological review is mandatory during acute illness for patients with suspected ocular involvement. 1, 4

Supportive Ocular Care

While awaiting ophthalmology evaluation, initiate:

• Non-preserved ocular lubricants (hyaluronate or carmellose drops) every 2 hours throughout acute illness to prevent corneal exposure and dryness 1, 4
• Keep the affected area elevated to promote drainage of edema 3
• Apply emollients to keep skin hydrated and prevent cracking, but avoid applying products to active vesicular lesions 3

Pain Management

Address acute neuritis with appropriate analgesics as needed. 6 For severe pain, consider tricyclic antidepressants (like amitriptyline) or anticonvulsants in low dosages for neuropathic pain control. 6

Critical Pitfalls to Avoid

• Never use topical antivirals—they are substantially less effective than systemic therapy and are not recommended. 3, 4
• Do not use topical corticosteroids without concurrent systemic antiviral therapy, as steroids can potentiate viral replication and worsen disease. 4
• Do not stop treatment at exactly 7 days if lesions are still forming or haven't completely scabbed—short-course therapy is inadequate for VZV infection. 3

When to Escalate to IV Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours if any of the following develop: 3

• Disseminated herpes zoster (multi-dermatomal or visceral involvement)
• Suspected CNS involvement or encephalitis
• Severe ophthalmic disease with intraocular involvement
• Signs of immunocompromise or failure to respond to oral therapy

Monitoring During Treatment

• Assess for complete healing of lesions at follow-up 3
• Monitor renal function if using IV acyclovir 3
• Watch for new lesion formation—immunocompetent patients typically stop forming new lesions within 4-6 days 3
• If lesions fail to resolve within 7-10 days despite treatment, suspect acyclovir resistance and obtain viral culture with susceptibility testing 3

Prevention of Future Episodes

Once acute symptoms resolve (typically waiting at least 2 months after the episode), administer Shingrix vaccination in a two-dose series given 2-6 months apart, which provides 97.2% efficacy in preventing future episodes. 1, 3 Having shingles once does not provide reliable protection, with a 10-year cumulative recurrence risk of 10.3%. 1

Special Considerations for This Location

The risk of dissemination without prompt antiviral therapy is 10-20%, with potential for viral pneumonia, encephalitis, and hepatitis. 1 Facial zoster requires particular attention due to risk of cranial nerve complications beyond just ocular involvement. 3 The patient should avoid contact with susceptible individuals (those who haven't had chickenpox) until all lesions have crusted, as vesicle fluid contains infectious viral particles. 3, 7