What is the recommended treatment for an adult with a history of chickenpox presenting with shingles on the face, potentially compromising ocular involvement?

Treatment of Shingles on the Face with Potential Ocular Involvement

Immediately initiate oral valacyclovir 1000 mg three times daily for 7 days, ideally within 72 hours of rash onset, and arrange urgent ophthalmology referral within 24 hours for any patient with facial shingles due to the high risk of vision-threatening complications. 1

First-Line Antiviral Therapy

Valacyclovir is the preferred oral antiviral due to superior bioavailability and simpler dosing that improves compliance compared to acyclovir. 1 The standard regimen is:

• Valacyclovir 1000 mg three times daily for 7 days 1
• Alternative: Acyclovir 800 mg five times daily for 7-10 days 2
• Alternative: Famciclovir 500 mg three times daily for 7 days 3

Timing is critical: Treatment must be initiated within 72 hours of rash onset to be effective in reducing post-herpetic neuralgia and ocular complications. 4 However, even if presenting beyond 72 hours, antiviral therapy should still be initiated for facial involvement given the risk of serious ocular disease. 1

Mandatory Ophthalmology Referral

Immediate ophthalmology referral is mandatory for management of any varicella zoster virus ocular disease involving the face. 1 Urgent referral within 24 hours is required if any of the following are present: 5

• Visual changes or decreased vision
• Moderate-to-severe eye pain
• Photophobia
• Corneal involvement
• Severe purulent discharge
• Vesicles on the eyelid or near the eye

Hutchinson's sign (vesicles on the tip of the nose) indicates nasociliary nerve involvement and predicts a 76% risk of ocular complications. 1

Adjunctive Topical Therapy for Eyelid Involvement

If vesicles are present on the eyelids:

• Apply topical antibiotics to eyelid vesicles to prevent secondary bacterial infection, which can lead to necrosis, scarring, and cicatricial ectropion. 3, 1
• Vesicles on eyelid margins are particularly vulnerable to bacterial superinfection as they undergo necrosis before healing. 3

Critical Corticosteroid Precautions

Never use topical corticosteroids during active epithelial viral infection as they potentiate viral replication and worsen disease. 1 This is a common and dangerous pitfall. Corticosteroids may only be considered for inflammatory complications without epithelial disease, under direct ophthalmologist supervision. 1

Monitoring for Ocular Complications

Patients with facial shingles are at risk for multiple vision-threatening complications: 1

• Pseudodendrites and dendritic keratitis
• Punctate keratitis and stromal keratitis
• Corneal scarring and vascularization
• Uveitis/iritis and sectoral iris atrophy
• Secondary glaucoma
• Neurotrophic keratitis from corneal anesthesia
• Dry eye

Daily ophthalmological review is necessary during acute illness for any periocular rash with ocular involvement. 5

Dose Adjustments for Renal Impairment

For patients with renal impairment, acyclovir dosing must be adjusted: 2

• Creatinine clearance 10-25 mL/min: 800 mg every 8 hours
• Creatinine clearance 0-10 mL/min: 800 mg every 12 hours
• Hemodialysis patients: Administer additional dose after each dialysis

Valacyclovir and famciclovir also require renal dose adjustments. 6

Special Populations

Immunocompromised patients require more aggressive treatment with possible dose adjustments and prolonged duration based on clinical response. 3, 1 These patients are at higher risk for:

• Disseminated cutaneous disease
• Visceral involvement (pneumonia, encephalitis, hepatitis)
• Chronic or recurrent shingles 7

Follow-Up Protocol

Schedule follow-up within 1 week of treatment initiation to assess for: 1

• Resolution of acute symptoms
• Development of complications
• Visual acuity measurement
• Slit-lamp biomicroscopy

If symptoms persist beyond 2-3 weeks or worsen at any time, re-evaluate immediately. 3

Prevention

The CDC strongly recommends recombinant zoster vaccine (RZV) for all immunocompetent patients aged 50 years and older to prevent herpes zoster and its complications, with 96% efficacy. 1 This should be discussed with patients after recovery from acute infection.

Common Pitfalls to Avoid

• Never delay antiviral therapy for viral cultures or confirmatory testing if herpes zoster is suspected clinically. 5
• Never use topical antivirals alone for VZV conjunctivitis—they are not helpful as monotherapy. 1
• Never use topical corticosteroids without concurrent antiviral therapy and ophthalmologist supervision. 5
• Do not assume the absence of eye symptoms means no ocular involvement—occult keratitis or uveitis may be present and requires slit-lamp examination. 1