A young girl with blisters on her forehead
Diagnosis: Herpes zoster ophthalmicus
This case of herpes zoster ophthalmicus (HZO) was unusual—not because of the way the patient presented, but because of her age. This condition is rarely seen in children, though it is not uncommon in adults—specifically, patients who are 60 years of age and older.1-4
Herpes zoster ophthalmicus, which refers to the involvement of the ophthalmic branch of the trigeminal nerve or the fifth cranial nerve, usually manifests with a typical vesicular or bullous eruption of the forehead, often in unilateral fashion. The lesions of herpes zoster (shingles) are similar to those of varicella (chickenpox) but in herpes zoster, painful unilateral vesicular eruptions are usually limited to one dermatome. (If hematogenous dissemination occurs, more than 20 vesicles will form in skin areas away from the affected dermatome.1)
Patients typically present with fever, headache, and abnormal sensations that precede the development of cutaneous lesions by a few days. The eruptions may be pustular and hemorrhagic initially, and within 10 days evolve into crusts.5,6
Differential diagnosis: Pain sets HZO apart
In its classical presentation, HZO does not pose a diagnostic challenge for practitioners well-versed in skin disease management. The clinical differential diagnosis of herpes zoster will include other causes of blisters or vesicular eruptions of autoimmune etiologies, viral infections, or hypersensitivity reactions.
The most common blistering diseases that may be mistaken for zoster include herpes simplex, contact dermatitis, erythema multiforme, and cellulitis. The prodromal stage and the characteristics of pain usually set herpes zoster apart from the other diagnoses.
Beware of complications
Eye complications. HZO may result in paralytic ptosis, conjunctivitis, keratitis, cataracts, glaucoma, retinitis, and optic neuritis and atrophy.2,5,7
Herpetic lesions on the tip of the nose are believed to herald ocular involvement and may precede typical dermatomal eruption of HZO.2 Such cutaneous involvement along the distribution of the nasociliary nerve is called Hutchinson’s sign. It should prompt a complete ophthalmologic evaluation, as it did with our patient.
Neurologic complications. The most common complication of herpes zoster infection in general is postherpetic neuralgia (PHN), which results in severe pain that persists for months—or years—after the skin lesions have completely healed. Patients over 70 have a 70% chance of developing PHN.4,7
Neurological complications such as encephalitis, myelitis, and Guillain-Barré syndrome have also been reported.
Other complications. Other complications include secondary bacterial infections, pneumonitis, and polyradiculitis.
