This patient has herpes zoster infection involving the forehead and has a vesicular lesion on the tip of the nose (Hutchinson sign) suggesting the possibility of ocular involvement, and she should be referred for urgent ophthalmologic evaluation. This clinical scenario is consistent with herpes zoster infection involving the V1 distribution of the trigeminal nerve, which can result in eye involvement (herpes zoster ophthalmicus) and ophthalmologic complications including keratitis, scleritis, uveitis, and acute retinal necrosis. When grouped vesicles on an erythematous base involve the V1 distribution or extend to the tip of the nose, concurrent management with an ophthalmologist is indicated to help treat and prevent any of these complications. Management of these patients usually involves antiviral therapy and topical glucocorticoid eye drops to reduce inflammation.
The herpes zoster vaccine is recommended for persons 60 years or older to prevent herpes zoster and its complications. The administration of the vaccine after an episode of zoster is debated. The Centers for Disease Control recommends providing the vaccine even after an initial herpes zoster infection. However, a recent article states that the cellular immune response to varicella zoster virus (VZV) during the first 3 years after vaccination is similar to that after an episode of herpes zoster. As a result, deferring vaccination for up to 3 years in patients who are immunocompetent, such as this patient, is recommended, as vaccination during the episode will not be as effective.
Mupirocin is an antibiotic used for the treatment of bacterial skin infections such as impetigo, furuncles, or methicillin-resistant Staphylococcus aureus. Herpes zoster is a viral infection, and mupirocin would not be appropriate.
Otolaryngology consultation is not necessary. The distribution of the vesicles in the central face is not concerning for underlying hearing or other otolaryngologic involvement. Herpes virus infection may involve the ear canal and hearing may be affected and a facial nerve palsy or vertigo also can result. This complex of findings is known as Ramsay Hunt syndrome, and systemic glucocorticoids and antiviral agents may be necessary to treat this complication, usually with co-management with an otolaryngologist.