The Facts About Orofacial Herpes Zoster: What You Need to Know

By Dr. Olasunkanmi Onifade

Introduction

Orofacial herpes zoster infection is the one caused by the Varicella-zoster virus (the virus that causes chickenpox) becoming active again, this time affecting the mouth and face. It presents as a painful rash and sores on the face and soft tissues inside the mouth.

Herpes zoster infection is a severe viral infection that impacts health and well-being. Also known as shingles, the causative virus is the Varicella-zoster virus, a DNA virus belonging to the herpes virus family of viruses.¹ It is the same virus responsible for chickenpox, a childhood illness associated with fever and skin rashes. People who have had chickenpox are at higher risk of herpes zoster infection later in life.

Distribution

Orofacial herpes zoster has a worldwide distribution and affects males and females in equal proportions. People who are over the age of 65 are more susceptible to the infection, which can have profound effects on an individual’s quality of life.

What are the risk factors?

• Persons who have had chickenpox earlier in life
• Older persons above 65 years
• Persons undergoing cancer treatment
• Diabetes mellitus
• HIV/AIDS
• Malnutrition
• Organ transplant recipients
• Medications that suppress the immune system, e.g steroids
• Physical and emotional stressors

How does orofacial herpes zoster occur?

Herpes zoster infection is highly contagious. A previously uninfected person can become infected through direct contact with fluid from blisters of someone with active shingles. It takes about 10-21 days between being infected with the virus and the appearance of signs and symptoms. This period is known as the incubation period.

Orofacial herpes zoster typically has a sudden onset with signs and symptoms resulting from viral infection of the trigeminal nerve. The trigeminal nerve is a large nerve that is divided into 3 parts and helps you feel sensations like pain, touch, temperature and pressure. It is the fifth and largest of the twelve pairs of nerves that run from the brain to different parts of the body. Collectively, these 12 nerves are known as the cranial nerves and serve major functions in the body.

What to look out for

The signs and symptoms of orofacial herpes zoster can result from the involvement of one or more parts of the trigeminal nerve. Oftentimes, the symptoms progress in three phases – prodromal, acute, and chronic phases.²

Prodromal phase

• Facial pain that sometimes mimics a toothache
• Headache
• Fever
• Tingling and numbness around the affected areas.
• Loss of appetite
• Tiredness

Acute phase

• Facial swelling
• Redness of facial skin
• Presence of itchy blisters and rashes on one side of the face and oral mucosa corresponding with the affected division of the trigeminal nerve. The one-sided appearance of blisters and rashes is a characteristic feature of the disease that can easily give away the diagnosis.
• Tingling and Numbness
• Severe destruction of bone and other tooth-supporting tissues³.
• Looseness of one or more teeth
• Ulcers in the mouth

Chronic Phase

• Post-herpetic neuralgia.

When is a diagnosis of orofacial herpes zoster made?

The characteristic features outlined above are often sufficient in making a diagnosis. However, a diagnosis can be further confirmed by carrying out several special investigations. These include serology, polymerase chain reaction, biopsy, and immunofluorescence studies.⁴

Treatment

Treatment is essentially medical, and an early diagnosis can accelerate recovery and prevent severe and debilitating complications such as post-herpetic neuralgia. Agents employed in treatment include:  

• Antiviral medications – eliminate the causative viral pathogen
• Steroids – Relieve inflammation
• Analgesics– Opioids or NSAIDS to relieve pain
• Antibiotics – when there is a superimposed bacterial infection
• Vitamin C – To support the healing process
• Supportive therapy – Hydration, rest, nutritive diet

Strategies for Prevention

1. Vaccination against chickenpox: A live attenuated vaccine is available against chickenpox and is administered in 2 different doses at 12-15 months and 4-6 years.
2. Vaccination against shingles is also available, e.g Shingrix (GSK)
3. Hand washing
4. Contact Precautions

Other medical specialities may be involved in the management of this condition. These include ophthalmologists, ENT surgeons,

Complications

Post-herpetic neuralgia – A chronic facial pain disorder due to nerve damage associated with herpes zoster infection. Pain can last from weeks to months and can be treated with anti-seizure drugs such as gabapentin and pregabalin or anti-depressant drugs like amitriptyline ^5,6

• Scar formation on the face
• Post-inflammatory hyperpigmentation – affected areas become darker after healing is complete
• Tooth loss
• Deafness
• Residual facial paralysis

Conclusion

• Toothache can be the initial symptom in patients with orofacial herpes zoster infection.
• Early diagnosis and treatment can accelerate recovery and decrease the risk of severe complications
• The prevention of chicken pox and herpes zoster can be achieved through vaccination.

 References

1. Dosi TR, Chawla AK, Barkalle G, Phulambrikar T. Herpes zoster of orofacial region. J Oral Maxillofac Pathol. 2021 Sep-Dec;25(3):557. doi: 10.4103/jomfp.jomfp_212_21. Epub 2022 Jan 11. PMID: 35281131; PMCID: PMC8859590.
2. Gurung D, Joshi U, Chaudhary B. Orofacial Herpes Zoster Infection in Dental Practice: A Case Report. JNMA J Nepal Med Assoc. 2020 Nov 22;58(231):941-944. doi: 10.31729/jnma.5310. PMID: 34506415; PMCID: PMC7775002.
3. Mancini A, Chirico F, Inchingolo AM, Piras F, Colonna V, Marotti P, Carone C, Inchingolo AD, Inchingolo F, Dipalma G. Osteonecrosis of the Jaws Associated with Herpes Zoster Infection: A Systematic Review and a Rare Case Report. Microorganisms. 2024; 12(8):1506. https://doi.org/10.3390/microorganisms12081506
4. Navghare S, Mohod S, Shinde SB, Thakre V. Herpes Zoster Infection of Orofacial Region in a Geriatric Patient: A Case Report. Cureus. 2024 Jun 10;16(6):e62049. doi: 10.7759/cureus.62049. PMID: 38989324; PMCID: PMC11234480.
5. Liu Y, Liu H, Bian Q, Zhang S, Guan Y. Impact of Herpes Zoster and Postherpetic Neuralgia on the Quality of Life in China: A Prospective Study. Clin Cosmet Investig Dermatol. 2024 Aug 26;17:1905-1915. Doi: 10.2147/CCID.S471823. PMID: 39220293; PMCID: PMC11363943.
6. Adriaansen EJM, Jacobs JG, Vernooij LM, van Wijck AJM, Cohen SP, Huygen FJPM, Rijsdijk M. 8. Herpes zoster and post herpetic neuralgia. Pain Pract. 2024 Oct 4;25(1):e13423. doi: 10.1111/papr.13423. Epub ahead of print. PMID: 39364882; PMCID: PMC11683194.

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Pic Credits: Dr Olasunkanmi Onifade

Declaration : The patient whose images appear in this article gave verbal consent for its use for educational purposes.