Herpes zoster ophthalmicus — SCE Dermatology MCQ

Correct answer: D — Same-day oral antiviral therapy and ophthalmology review

The correct answer is D, same-day oral antiviral therapy and ophthalmology review. The distribution over the forehead and upper eyelid respecting the midline confirms trigeminal V1 (ophthalmic) dermatome shingles, and vesicles on the nasal tip (Hutchinson's sign) indicate nasociliary nerve involvement, a strong predictor of ocular complications such as keratitis, uveitis and scarring. Blurred vision and conjunctival injection signal active ocular involvement, making this herpes zoster ophthalmicus a same-day ophthalmic emergency. Oral aciclovir or valaciclovir started promptly reduces viral replication, dermatological severity and the risk of sight-threatening keratouveitis, while urgent ophthalmology assessment is needed to exclude keratitis, uveitis and secondary glaucoma. This combination, systemic antiviral plus urgent specialist eye review, is the guideline-directed standard of care for suspected HZO with ocular signs. Why the other options are wrong: C. Topical corticosteroid to the eyelid skin: steroids applied without antiviral cover can potentiate viral replication and worsen corneal or ocular disease, and do nothing to address the underlying VZV reactivation or ocular risk. E. Reassurance with analgesia alone: this ignores the Hutchinson's sign and ocular signs, both of which mandate urgent antiviral treatment and ophthalmic assessment to prevent permanent visual loss. B. Permethrin cream to scalp and face: permethrin treats scabies or lice, not a viral vesicular eruption; the clinical picture (dermatomal distribution, grouped vesicles, neuralgic pain) is not consistent with an infestation. A. Topical fusidic acid as sole therapy: fusidic acid is an antibacterial for secondary bacterial infection, not an antiviral, and using it alone leaves the active VZV infection and ocular threat untreated. Key point: Vesicles on the tip or side of the nose (Hutchinson's sign) in ophthalmic shingles predict ocular involvement and mandate same-day antiviral therapy plus urgent ophthalmology review.

Reference: NICE CKS, Shingles: Diagnosis and Management (last revised), cks.nice.org.uk/topics/shingles