Herpes Zoster Ophthalmicus (Shingles)
This 6-year-old has herpes zoster ophthalmicus (HZO) until proven otherwise, and requires immediate systemic antiviral therapy with oral acyclovir 800 mg five times daily for 7 days (or valacyclovir 1000 mg three times daily for 7 days) plus urgent ophthalmology referral within 24 hours to prevent vision-threatening complications. 1, 2
Diagnosis
The unilateral vesicular rash in a dermatomal distribution on one side of the face under the eye is pathognomonic for varicella-zoster virus (VZV) reactivation. 1, 3
Key diagnostic features to confirm:
- Vesicular dermatomal rash with unilateral distribution—this is the hallmark finding 1
- Pain or severe discomfort often precedes the rash by 24-72 hours, though children may have less pain than adults 3
- Bulbar conjunctival injection with watery discharge if ocular involvement is present 1
- Palpable preauricular lymph node on the affected side 1
While HZO is uncommon in healthy children, it does occur even in immunocompetent 6-year-olds, particularly after early varicella exposure (in utero, vaccination, or early childhood infection). 4, 5, 6
Immediate Treatment Protocol
Systemic antiviral therapy must be started immediately—do not wait for laboratory confirmation: 2
- Valacyclovir 1000 mg three times daily for 7 days (preferred due to superior bioavailability and simpler dosing) 2
- Alternative: Acyclovir 800 mg five times daily for 7 days 2, 5
- Alternative: Famciclovir 500 mg three times daily for 7 days 2
Topical management of eyelid vesicles:
- Apply topical antibiotic ointment (such as bacitracin or erythromycin) to eyelid vesicles to prevent secondary bacterial infection, which can cause necrosis, scarring, and cicatricial ectropion 2
- Cold compresses for symptomatic relief 2
- Oral analgesics for pain management 2
Critical: Urgent Ophthalmology Referral
This child requires ophthalmology evaluation within 24 hours because periocular VZV carries significant risk of vision-threatening complications. 2
Examine for these red flags requiring immediate ophthalmology consultation:
- Conjunctival injection beyond simple eyelid involvement 1, 2
- Vesicles at the limbus (junction of cornea and sclera) 1
- Any visual symptoms, eye pain, or photophobia 7
- Hutchinson's sign (vesicles on the tip of the nose, indicating nasociliary nerve involvement and higher risk of ocular complications) 8
Potential vision-threatening sequelae include:
- Punctate or pseudodendritic keratitis 1
- Stromal keratitis with corneal scarring 1, 2
- Uveitis 1, 2
- Corneal anesthesia leading to neurotrophic keratopathy 1
- Retinitis 1, 2
What NOT to Do
Never use topical corticosteroids alone for VZV eyelid lesions—they potentiate viral replication and worsen disease. 2
Do not use topical antivirals alone—they are inadequate for preventing systemic and ocular complications. 7, 2
Do not delay treatment waiting for PCR confirmation—treat based on clinical diagnosis as delaying treatment significantly reduces efficacy. 7
Follow-Up and Monitoring
Schedule follow-up within 1 week to assess treatment response and monitor for complications: 2
- Visual acuity measurement 2
- Slit-lamp examination to detect early corneal involvement 2
- Assessment for post-herpetic neuralgia (less common in children but possible) 8
Re-evaluate immediately if:
Immunocompromised Considerations
While this child is described as otherwise healthy, screen for underlying immunodeficiency if HZO occurs in a child this young, as reactivation is uncommon in immunocompetent children: 3, 4
- HIV testing 3
- Diabetes screening 3
- Evaluation for malignancy 3
- Review of any immunosuppressive medications 3
If immunocompromised, consider more aggressive therapy with possible IV acyclovir and prolonged treatment duration. 3, 2