What is the recommended treatment for an adult, possibly in their 50s or older, with a history of varicella-zoster virus infection, presenting with forehead shingles and headaches?

Treatment of Forehead Shingles with Headaches

Initiate oral valacyclovir 1000 mg three times daily for 7-10 days immediately, ideally within 72 hours of rash onset, and continue treatment until all lesions have completely scabbed. 1, 2, 3

Immediate Antiviral Treatment

First-line oral therapy options:

• Valacyclovir 1000 mg three times daily for 7-10 days is the preferred first-line treatment due to superior bioavailability and less frequent dosing compared to acyclovir 1, 3
• Acyclovir 800 mg five times daily for 7-10 days is an alternative, though requires more frequent dosing 1, 2
• Treatment must be initiated within 72 hours of rash onset for optimal efficacy in reducing acute pain, accelerating lesion healing, and preventing postherpetic neuralgia 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, 2

Critical Assessment for Escalation to IV Therapy

Evaluate immediately for the following high-risk features that require intravenous acyclovir 10 mg/kg every 8 hours:

• Multi-dermatomal involvement or disseminated disease 1, 2
• Ophthalmic involvement (forehead location raises concern for ophthalmic zoster via V1 trigeminal distribution) 1, 2
• Severe immunosuppression (HIV with CD4 <100, active chemotherapy, high-dose steroids ≥20 mg/day prednisone for ≥2 weeks) 4, 1
• CNS complications such as severe headache with altered mental status, meningismus, or focal neurological deficits 1, 2
• Failure to respond to oral therapy within 7-10 days 1

Special Considerations for Forehead Location

Forehead shingles warrants heightened vigilance due to ophthalmic nerve involvement:

• Facial zoster requires particular attention due to risk of cranial nerve complications 2
• Assess for eye involvement: visual changes, eye pain, conjunctival injection, or Hutchinson's sign (vesicles on tip of nose indicating nasociliary nerve involvement) 2
• Consider ophthalmology referral if any ocular symptoms present 4, 5
• Headaches may represent acute neuritis (expected) versus CNS involvement (requires IV therapy) 1, 2

Pain Management

Address acute pain aggressively:

• Analgesics ranging from acetaminophen/NSAIDs to opioids may be required for adequate pain control during the acute phase 5, 6
• Avoid topical corticosteroids on active vesicular lesions, as they can worsen infection and increase dissemination risk 2
• Oral corticosteroids (prednisone) may provide modest benefit in reducing acute pain but carry significant risks (infections, hypertension, osteopenia) that generally outweigh benefits in most patients 2, 5

Monitoring and Follow-Up

Key monitoring parameters:

• Assess for complete scabbing of all lesions before discontinuing antiviral therapy 1, 2
• Monitor for development of new lesions beyond 4-6 days (suggests possible immunocompromise requiring extended treatment) 2
• If lesions fail to begin resolving within 7-10 days, suspect acyclovir resistance and obtain viral culture with susceptibility testing 2
• Monitor renal function if using IV acyclovir, with dose adjustments for creatinine clearance <50 mL/min 1, 3

Prevention of Future Episodes

Vaccination after recovery:

• Recombinant zoster vaccine (Shingrix) is recommended for all adults aged ≥50 years, regardless of prior herpes zoster episodes 4, 1, 2
• Shingrix can be considered after recovery from this acute episode to prevent future recurrences 2
• Shingrix is preferred over the live attenuated vaccine (Zostavax) due to superior efficacy (>90% vs 51-70%) and longer duration of protection 4

Common Pitfalls to Avoid

• Do not delay treatment waiting for laboratory confirmation—clinical diagnosis is sufficient in immunocompetent patients with typical presentation 2
• Do not stop antivirals at exactly 7 days if lesions are still forming or have not completely scabbed 2
• Do not use topical antivirals—they are substantially less effective than systemic therapy 2
• Do not dismiss severe headaches in forehead zoster without ruling out CNS complications or ophthalmic involvement 1, 2