A Man with a Rash on the Scalp and Face

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Posted by Carla Rothaus

Which components of the ocular system may be involved in herpes zoster ophthalmicus?

Herpes zoster ophthalmicus is due to reactivation of varicella–zoster virus infection. Read the NEJM Case Records of the Massachusetts General Hospital here.

Clinical Pearls

Q: How common is herpes zoster ophthalmicus?

A: Up to 30% of people in the United States have reactivation of varicella–zoster virus infection in their lifetime, and 10 to 20% of cases involve the ophthalmic division of the trigeminal nerve.

Q: How do patients describe the pain associated with the rash that develops with herpes zoster ophthalmicus?

A: At the onset of the rash, most patients with herpes zoster ophthalmicus have acute pain caused by the associated inflammation and damage to the sensory nerve and affected skin. The pain has been described as itching, burning, aching, and piercing. Up to 75% of patients with zoster have prodromal pain.


Morning Report Questions

Q: Which components of the ocular system may be involved in herpes zoster ophthalmicus?

A: Up to two thirds of patients with herpes zoster ophthalmicus have ocular manifestations in addition to the cutaneous lesions. These can affect the cornea, conjunctiva, iris, retina, optic nerve, and other parts of the ocular system. Conjunctival injection and chemosis commonly occur with herpes zoster ophthalmicus. Of note, approximately 30 to 40% of patients with herpes zoster ophthalmicus have involvement of the nasociliary branch of the ophthalmic nerve, which innervates the skin of the nose and the cornea. Thus, the presence of unilateral involvement of the nose (Hutchinson sign) increases the likelihood of ocular involvement.

Q: Describe features of the rash associated with herpes zoster ophthalmicus.

A: The rash that develops in patients with herpes zoster ophthalmicus, which is the same as that seen with herpes zoster involving other regions of the body, is characterized by erythema, macules, papules, and vesicles. The vesicles can erupt progressively, over a period of several days, and then evolve into pustules and crust, often with surrounding erythema and edema. Herpes zoster classically affects a single dermatome and usually does not cross the midline. In some cases, localized zoster can involve one or two adjacent dermatomes. Progression of the disease to affect the contralateral side, referred to as herpes zoster multiplex bilateralis, is atypical in immunocompetent hosts, but it can occur. Acyclovir is the standard treatment for herpes zoster ophthalmicus. Cutaneous lesions can continue to form for 3 to 7 days after the initiation of antiviral therapy.

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