What is the recommended management for an otherwise healthy adult with herpes zoster oticus limited to the ear without additional symptoms?

Management of Herpes Zoster Oticus Without Additional Symptoms

For an otherwise healthy adult with herpes zoster limited to the ear without facial paralysis, hearing loss, or other complications, initiate oral valacyclovir 1 gram three times daily for 7 days as soon as possible, ideally within 72 hours of symptom onset. 1, 2, 3

Diagnostic Confirmation and Risk Assessment

The clinical presentation of herpes zoster oticus (also called Ramsay Hunt syndrome when complicated) includes vesicles on the external ear canal and posterior auricular surface with severe otalgia. 4 However, your patient presents with herpes zoster around the ear without any other symptoms—meaning no facial paralysis, no loss of taste, no decreased lacrimation, and no hearing loss. 4 This represents uncomplicated herpes zoster oticus rather than full Ramsay Hunt syndrome.

Key clinical distinction: The absence of facial nerve involvement, cranial nerve deficits, or systemic symptoms allows for outpatient oral antiviral therapy rather than requiring intravenous treatment. 4, 1

First-Line Antiviral Treatment

Valacyclovir 1 gram orally three times daily for 7 days is the preferred first-line therapy. 1, 2, 3 This regimen offers:

• Superior bioavailability compared to acyclovir (three- to fivefold higher), allowing less frequent dosing 5, 6
• Proven efficacy in accelerating resolution of zoster-associated pain and reducing postherpetic neuralgia duration 5, 6
• Simpler dosing schedule (three times daily versus five times daily for acyclovir), improving adherence 5, 6

Alternative option: Acyclovir 800 mg orally five times daily for 7-10 days is acceptable if valacyclovir is unavailable or cost-prohibitive. 1, 2, 3

Critical timing: 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, 7, 2 However, observational data suggest benefit even when started beyond 72 hours, so do not withhold treatment if the patient presents late. 5

Treatment Duration and Monitoring

Continue antiviral therapy until all lesions have completely scabbed—this is the key clinical endpoint, not an arbitrary 7-day calendar duration. 1, 2 If lesions remain active beyond 7 days, extend treatment accordingly. 1

Monitor for:

• Development of facial weakness or paralysis (would indicate progression to Ramsay Hunt syndrome requiring urgent escalation) 4, 7
• New vesicles in multiple dermatomes (suggests dissemination requiring IV therapy) 1, 2
• Hearing loss, vertigo, or tinnitus (indicates inner ear involvement) 4
• Severe or worsening pain despite treatment (may require adjunctive pain management) 1

Pain Management

For acute neuropathic pain associated with herpes zoster oticus:

• Gabapentin is first-line for acute neuropathic pain, titrated in divided doses up to 2400 mg per day. 1
• Over-the-counter analgesics (acetaminophen, ibuprofen) for mild-to-moderate pain 1
• Avoid topical antivirals—they are substantially less effective than systemic therapy and not recommended. 1, 2

When to Escalate to Intravenous Therapy

Switch to intravenous acyclovir 10 mg/kg every 8 hours if any of the following develop: 1, 7, 2

• Facial paralysis or other cranial nerve deficits
• Disseminated herpes zoster (≥3 dermatomes or visceral involvement)
• Signs of CNS involvement (meningismus, altered mental status)
• Inability to tolerate oral medications
• Immunocompromised status (though your patient is otherwise healthy)

Prevention of Future Episodes

After recovery from the current episode, strongly recommend the recombinant zoster vaccine (Shingrix) for all adults aged ≥50 years, regardless of this prior episode. 1, 2 The vaccine provides >90% efficacy in preventing future herpes zoster recurrences. 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for confirmatory testing—herpes zoster oticus is a clinical diagnosis, and antiviral therapy should begin immediately. 7
• Do not discontinue treatment at exactly 7 days if lesions are still forming or have not completely scabbed. 1, 7
• Do not use topical antivirals as primary therapy—they are ineffective for herpes zoster. 1, 2
• Do not assume the patient is "too late" for treatment if presenting beyond 72 hours—observational data support benefit even with delayed initiation. 5