Zoster of the 2nd and 3rd trigeminal branch

Last Updated: 2019-08-26

Author(s): -

Herpes Zoster-Infektion im Innervationsgebiet des 2. und 3. Trigeminusasts.

Image of herpes zoster in the area of the cheeks as well as the oral mucosa and tongue. Enorally, the efflorescences can also appear aphthoid or erosive.

Gingivitis 

  • Light shield
  • Contact with pregnant women or small children should be avoided if possible.

  • In young patients, the exclusion of immunosuppression (especially HIV) makes sense.

  • Demand-oriented analgesic therapy. 

     

    Pain treatment 

    Always adequate pain therapy to reduce risk of post-zoster neuralgia.

    Therapy of postzosteric neuralgia (stage scheme).

     

    1st stage NSAID (e.g. ibuprofen, max. 2.4g/d) or paracetamol max. 4d/d.

     

    2nd stage additionally weak opioid analgesics (e.g. Tramadol 200-400mg/d).

     

    3rd stage (in addition to stage 1) highly effective opioid analgesics (e.g. oxycodone).

     

    4th stage (in addition to stage 1 or 2) anticonvulsants (e.g. gabapentin max. 3.6g/d), pregabalin max. 600mg/d or antidepressants (e.g. amitriptyline max. 150mg/d); presentation in the pain consultation.

     

     

    Systemic Therapy

  • Absolute indications for systemic treatment, ideally within the first 72 hours after infection 

  • Age > 50 years.
  • Extra-trunkal infestation.
  • Moderate or severe pain.
  • Pronounced local findings.
  • Immunosuppression.

  • Infestation of internal organs.
  • An early start is essential for any antiviral therapy.
  • Start of therapy < 72h after onset of skin symptoms or > 72h after onset of skin symptoms when new blisters are formed. In addition, there is an increased risk of secondary bacterial infection. 

     

    Acyclovir (Zovirax®)

  • Application: at 3x 5mg/kg bw/d intravenously or 5x 800mg/d p.o., with immunosuppression 10mg/kg bw/d intravenously 

  • Contraindication: hypersensitivity, breastfeeding (because of transfer to breast milk)

  • Side effects (very common): headache, nausea 

  • CAVE:
  • In older patients there is an increased risk of reversible neurological disorders.

  • Adjustment of dosage for reduced kidney function.

  • Sufficient liquid supply.

     

    Valaciclovir (Valtrex®)

  • Application: 1 g 3x/d for 7d

  • Contraindication: Hypersensitivity, lactation.

  • Side effects (frequent): headache, nausea.

  • CAVE:
  • Adjustment of dosage for reduced kidney function.

  • Hydration state.

     

    Brivudine (Brivex®- Tbl.)

  • Off-lable-use 
  • Daily dosage: 125 mg 1x/d for 7 days 

  • Drug interaction: 5-fluorouracil preparations (at least 4 weeks apart).

  • Side effects (frequent): Nausea.

  • Contraindication: 5-fluorouracil therapy, pregnancy, lactation, hypersensitivity to ingredients, not tested on children and adolescents.

     

 

          Famciclovir (Famvir®)

  • Application: 500 mg 2x/d
  • In patients >50, 500mg should be given 3x/d to prevent zoster neuralgia.

  • Independent of meals.

  • Drug interaction: Probenecid.
  • Contraindication: Pregnancy, lactation, hypersensitivity to famciclovir or penciclovir.

  • CAVE:
  • Patients at risk of dehydration, especially older patients, should pay attention to adequate hydration.

  • Efficacy in black patients may be reduced. 

            

    Foscarnet (Foscavir®)

  • for immunosuppression and acyclovir resistance 

  • Application: 3 x 40 mg/kg bw/d intravenously
  • Contraindication: hypersensitivity, pregnancy, lactation.
  • Side effects (very common): granulocytopenia, anorexia, hypokalemia, hypomagnesemia, hypocalcaemia, paresthesia, headache, dizziness, nausea, vomiting, diarrhea, rash, increased serum creatinine, fever, fatigue, chills, asthenia.

  • CAVE:
  • Adjustment of dosage for reduced kidney function.

  • enough fluid intake.

     

Topical Therapy 

  • Different local therapies depending on the clinic.

  • According to current guidelines, therapy with topical local anaesthetics and capsaicin is not recommended.  

  • Tannosynt®-Lsg. several times a day 

  • Iod-Povidon®sg. several times daily
  • Ialugen® Plus Cream several times a day
  • Fucidine® cream several times a day 
  • Fucicort® cream several times a day

 

  1. Pushpanshu, K., et al., An unusual complication of tooth exfoliation and osteonecrosis following herpes zoster infection of trigeminal nerve: a case report and literature review. Minerva Stomatol, 2013. 62(6): p. 241-5.
  2. Lovell, B., Trigeminal herpes zoster: early recognition and treatment are crucial. BMJ Case Rep, 2015. 2015.
  3. Lambade, P., et al., Maxillary osteonecrosis and spontaneous teeth exfoliation following herpes zoster. Oral Maxillofac Surg, 2012. 16(4): p. 369-72.
  4. Mohan, R.P., et al., Herpes zoster. BMJ Case Rep, 2013. 2013.
  5. Hatziotis, J.C., Herpes zoster of the maxillary nerve: report of a case. Dent Dig, 1972. 78(5): p. 242-6.
  6. Omoti, A.E. and C.E. Omoti, Maxillary herpes zoster with corneal involvement in a HIV positive pregnant woman. Afr J Reprod Health, 2007. 11(1): p. 133-6.
  7. Millar, E.P. and M.J. Troulis, Herpes zoster of the trigeminal nerve: the dentist's role in diagnosis and management. J Can Dent Assoc, 1994. 60(5): p. 450-3.
  8. Sato, M., et al., Herpes zoster of the maxillary branch of the trigeminus nerve. Virological and serological studies. Int J Oral Surg, 1979. 8(2): p. 149-54.
  9. Doan, K., K. Stoler, and K. Logan, Herpes Zoster of the Third Division of the Trigeminal Nerve. A Clinical Pathologic Conference. N Y State Dent J, 2015. 81(6): p. 50-4.
  10. Song, J.M., J.S. Seo, and J.Y. Lee, Mandibular osteonecrosis following herpes zoster infection in the mandibular branch of the trigeminal nerve: a case report and literature review. J Korean Assoc Oral Maxillofac Surg, 2015. 41(6): p. 357-60.
  11. Malhotra, R. and A. Karan, Herpes Zoster of Mandibular Division of Trigeminal Nerve (V3). J Assoc Physicians India, 2015. 63(7): p. 52.
  12. Rudd, T., et al., Mandibular osteonecrosis and Ramsay Hunt syndrome following a case of herpes zoster. J Oral Maxillofac Surg, 2014. 72(10): p. 1974 e1-6.
  13. Nair, P., et al., Herpes zoster on the face in the elderly. BMJ Case Rep, 2014. 2014.
  14. Dimisianos, N., et al., Trigeminal herpes zoster complicated by Ramsay Hunt syndrome. Neurologist, 2015. 19(2): p. 38-9.
  15. Hsieh, J.W., et al., Herpes zoster mandibularis. BMJ Case Rep, 2013. 2013.
  16. Vourexakis, Z. and J. Vanoy, Mucosal and cutaneous lesions in mandibular zoster. BMJ Case Rep, 2014. 2014.
  17. Shevick, I.M., Mandibular herpes zoster; with report on the use of cortisone in a case with geniculate ganglion symptoms. Calif Med, 1953. 79(6): p. 444-8.
  18. Werner RN, Nikkels AF, Marinovic B, Schafer M, Czarnecka-Operacz M, Agius AM, Bata-Csorgo Z, Breuer J, Girolomoni G, Gross GE, Langan S, Lapid-Gortzak R, Lesser TH, Pleyer U, Sellner J, Verjans GM, Wutzler P, Dressler C, Erdmann R, Rosumeck S, Nast A: European consensus-based (s2k) guideline on the management of herpes zoster - guided by the european dermatology forum (edf) in cooperation with the european academy of dermatology and venereology (eadv), part 1: Diagnosis. J Eur Acad Dermatol Venereol 2017;31:9-19.

  19. Werner RN, Nikkels AF, Marinovic B, Schafer M, Czarnecka-Operacz M, Agius AM, Bata-Csorgo Z, Breuer J, Girolomoni G, Gross GE, Langan S, Lapid-Gortzak R, Lesser TH, Pleyer U, Sellner J, Verjans GM, Wutzler P, Dressler C, Erdmann R, Rosumeck S, Nast A: European consensus-based (s2k) guideline on the management of herpes zoster - guided by the european dermatology forum (edf) in cooperation with the european academy of dermatology and venereology (eadv), part 2: Treatment. J Eur Acad Dermatol Venereol 2017;31:20-29.