Zoster of the 2nd and 3rd trigeminal branch

Zoster, shingles, chickepox, varicella

Herpes zoster occurs when the dormant varicella virus (after a primary chickenpox infection) is reactivated. The virus then travels from the ganglia to the area that is innervated by the 2nd and 3rd trigeminal branches.

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

Most often the diagnosis can be made clinically. In doubt, a viral swab and PCR can confirm the initial clinical suspicion.

Gingivitis, involvement of the ears which may cause vertigo and alteration of auditory function.

• Light protection
• Contact with pregnant women or young children should be avoided if possible
• In young patients, exclusion of immunosuppression (especially HIV) is useful
• Need-based analgesic therapy

Pain therapy

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

Therapy of post-zoster neuralgia (stepwise regimen)

• 1st stage NSAIDs (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) strong 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
• Extratruncal infestation
• Moderate or severe pain
• Extensive local findings
• Immune suppression
• Involvement of internal organs
• Early initiation
• is essential for any antiviral therapy
• Start therapy 72 h after the onset of skin symptoms or 72 h after the onset of skin symptoms when new vesicles are formed. In addition, there is an increased risk of secondary bacterial infection

Aciclovir

• dosage: at 3x 5mg/kg bw/d i.v. or 5x 800mg/d p.o., at immunosuppression 10mg/kg bw/d i.v.
• CI: Hypersensitivity, lactation (since transfer to breast milk)
• possible adverse effects (very common): headache, nausea
• CAVE:
  • In elderly patients, there is an increased risk for the occurrence of reversible neurological disorders
  • Adjust dosage if renal function is impaired
  • Enough fluid intake

Valaciclovir

• dosage: 1 g 3x/d for 7d
• CI: Hypersensitivity, lactation
• possible adverse effects  (common): headache, nausea
• CAVE:
  • Adjustment of dosage in impaired renal function
  • Hydration state

Brivudine (tbl.)

• off-label-use
• dosage: 125 mg 1x/d for 7 days
• interactions: 5-fluorouracil preparations (time interval at least 4 weeks)
• possible adverse effects (common): nausea
• CI: 5-fluorouracil- therapy, pregnancy, lactation, hypersensitivity to ingredient, not tested in children and adolescents

Famciclovir

• dosage: 500 mg 2x/d
• for pat. >50, 500mg 3x/d should be given to prevent zoster neuralgia
• independent on meals
• interactions: probenecid
• CI: Pregnancy, lactation, hypersensitivity to famciclovir or penciclovir
• CAVE:
  • In patients at risk of dehydration, especially elderly patients, adequate hydration should be ensured
  • Efficacy may be reduced in black patients

Foscarnet

• In immunosuppression and aciclovir resistance
• dosage: 3 x 40 mg/kg bw/d i.v.
• CI: hypersensitivity, pregnancy, lactation
• possible adverse effects (very common): granulocytopenia, anorexia, hypokalaemia, hypomagnesaemia, hypocalcaemia, paraesthesias, headache, dizziness, nausea, vomiting, diarrhoea, rash, increased serum creatinine, fever, fatigue, chills, asthenia
• CAVE:
  • Adjust dosage if renal function is impaired
  • Enough fluid intake

Topical therapy

• Different local therapies depending on the clinic
• Current guidelines do not recommend therapy with topical local anaesthetics and capsaicin.
• Tanning agents several times a day
• Iodine-povidone Lsg. several times a day
• Hyaluronic acid-sulfadiazine cream several times tgl.
• Fusidic acid cream several times tgl.
• Fusidic acid + betamethasone cream several times a day

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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.