(379) Persistent Painful Oral and Facial Lesions After V1/V2 Shingles

Introduction: Shingles, or herpes zoster, may present with oral or facial vesicles, and rash eruption classically follows dermatomal distributions. After the acute infectious phase has subsided, persistent sensory deficits and post-herpetic neuralgia (PHN) can be debilitating to patients and difficult to treat. There is little in the literature that addresses longstanding symptoms months after resolution of the initial rash.

Methods: Case presentation of a 45-year-old male with end-stage renal disease and history of chickenpox in childhood who was referred to ENT for several months of hyperpigmented oral lesions. On careful history, the patient revealed that he had painful vesicles 7 months previously that involved the right forehead, cheek, and palate. The rash subsided over 1-2 weeks, but he continued with decreased sensation to touch on the right upper- and mid-face with right mouth pain on eating. After several months of no relief, his primary care provider began Gabapentin 300mg QHS and lidocaine mouthwash. Sensation to touch was slowly improving, however there were persistent skin and mucosal changes. Exam revealed a hyperpigmented macular rash of the right V1 and V2 distributions of the facial skin. He had similar lesions over the right hard palate, which were exquisitely painful to touch.

Results: The patient was diagnosed with post-herpetic neuralgia. We increased his Gabapentin to 300mg TID and continued lidocaine mouthwash before meals to improve oral intake. A referral was placed for Neurology to consider Shingles vaccination.

Conclusions: Shingles classically begins with painful vesicular rash following dermatomal distributions, and most commonly results in complete resolution of symptoms over time. Involvement of the trigeminal distribution is common (10-20% of cases), and persistent pigmented facial or oral mucosal lesions may trigger referral to Otolaryngology. The literature reports 2-20% of shingles outbreaks are complicated by PHN. Patients’ pain should be controlled with appropriate medications, and shingles vaccination should be considered to prevent recurrence.