Herpes zoster

Change Language German

Herpes zoster ophthalmicus

  • Unilateral painful vesicular skin lesions in the innervation zone of the 1st trigeminal branch (V1)
    due to reactivation of Varicella zoster viruses
  • Cave: Hutchinson’s sign (tip of nose affected) -> sign of intraocular involvement
  • Medical history: duration of skin lesions, onset of symptoms -> relevant for treatment decision
  • Diagnosis: Clinical diagnosis, swab of skin lesions not mandatory if findings are clear

Herpes zoster Keratitis

  • Findings:
    • acute epithelial keratitis = keratitis dentritiformis
      • Pseudodendritica: weak fluorescein staining, central tree-like lesion, raised, rather pointed ends without terminal bulbs 1
      • Decreased corneal sensitivity in 50%, often progressing to neurotrophic keratopathy
    • nummular keratitis
      • about 10 days after onset of rash
    • Interstitial keratitis (= stromal keratitis)
      • in approx. 5% of patients; about 3 weeks after onset of rash

Herpes zoster Uveitis anterior

  • see Uveitis anterior
  • Keratouveitis: Uveitis anterior + keratitis
  • Findings: fine granulomatous endothelial precipitates, anterior chamber cells/flare, sectorial iris atrophy, increased eye pressure (due to iridocyclitis)


Other findings in herpes zoster

  • Conjunctivitis (papillary and/or follicular): frequent
  • Episcleritis: usually resolves spontaneously
  • Scleritis: rare; oral steroid therapy may be indicated
  • Acute retinal necrosis -> always dilate the pupils to examine the retina
  • Neurotrophic keratitis -> see neurotrophic keratopathy
  • CN III, IV, VI palsy


Herpes zoster Keratitis

  • Virgan gel (Gangciclovir) 5x/d (alternative Zovirax (aciclocir) ointment 5x/d) until lesions are healed or 3 days longer (not mandatory if treated systemically) for epithelial keratitis
  • Valtrex (Valacivlovir) 1g 3x/d for 7 to 10 days (consider treating longer until lesions are healed)
    • Start therapy within 72 hours after onset of disease if possible, but only within 5-7 days after onset
  • Additional local steroids for nummular or interstitial keratitis
    • e.g. Dexafree UD gtt (Dexamethasone) 4-5x/d, taper over 4-6 weeks

Zoster ophthalmicus (without eye involvement)

  • Valtrex 1g 3x/d for 7-10 days (to reduce risk of ocular involvement and post-herpetic neuralgia)
  • patients with zoster ophthalmicus should be regularly checked for ~6 weeks for ocular involvement (e.g. anterior uveitis, often asymptomatic)
  • topical therapy for skin lesions
    • e.g. Tanno Hermal Lotio several times a day
    • alternatively, if not superinfected (only crusted): Aqua Dalibouri solution (copper zinc solution), apply gauzes with solution 1x 15min per day
    • alternatively if superinfected: Fucicort cream 1-2x/day (Fusidic Acid/Betamethasone)

Zoster ophthalmicus with anterior uveitis

  • Valtrex 1g 3x/d for 7-10 days, then continue with reduced dose (e.g. 3x500mg)
  • Pred Forte AT initially hourly (or less depending on anterior chamber cells / flare) +/- Ultracortenol ointment (Prednisolone) at night; taper slowly if response is good
  • Scopolamine gtt 2x/d in case of severe inflammation (to prevent posterior synechiae)

Neuropathic pain

  • Lyrica (Pregabalin) 50mg p.o.
    • Dosing regimen: e.g. 1st day: 1-0-0, 2nd day: 1-0-1, 3rd day: 1-1-1, 4th day: 2-1-1, 5th day: 2-1-2, from 6th day: 2-2-2
  • if pain does not improve under 300 mg daily: admit to neurology

Acute retinal necrosis (ARN)


  • Evaluate long-term prophylaxis from 2 relapses/year, consider Valtrex 250mg 2x/d, high risk patients 2x500mg/d.
  • Vaccination (Shingrix): according to BAG 2 recommended for
    • immunocompetent patients between 65 – 79
    • immunocompromised patients over 50 years
    • in severe immunodeficiency from 18 years