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[1]                                                                                                                                                                                                                                              AJDHS.COM 

 

 

Available online at ajdhs.com 

Asian Journal of Dental and Health Sciences 
Open Access to Dental and Medical Research 

Copyright  © 2024 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 
which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided 

the original author and source are credited  

 

 

Multidermatomal Herpes Zoster of the trigeminal nerve in an 
immunocompetent patient: a case report 
Chia Earn Sun 1*, Sahrir Sanusi 1,2 

1) Postgraduate School of Medicine, KPJ Healthcare University College, Nilai, Negeri Sembilan, Malaysia 

2) KPJ Kajang Specialist Hospital, Kajang, Selangor, Malaysia 

Article Info: 
_____________________________________________ 
Article History: 

Received   09 December 2023     
Reviewed  11 January 2024 
Accepted   06 February 2024 
Published 15 March 2024 

_____________________________________________ 
Cite this article as:  

Sun CE, Sanusi S, Multidermatomal Herpes Zoster of 
the trigeminal nerve in an immunocompetent 
patient: a case report, Asian Journal of Dental and 
Health Sciences. 2024; 4(1):1-3 

DOI: http://dx.doi.org/10.22270/ajdhs.v4i1.67  
_____________________________________________ 

*Address for Correspondence:   

Chia Earn Sun, Postgraduate School of Medicine, 
KPJ Healthcare University College, Nilai, Negeri 
Sembilan, Malaysia 

Abstract 
_________________________________________________________________________________________________________________ 

Herpes Zoster is a neurocutaneous viral infection caused by the reactivation of the Varicella Zoster 
Virus in the dorsal root ganglion. It is characterized as vesicular rash along a unilateral dermatome, 
usually associated with pain or paresthesia of the involved area. Multidermatomal involvement is 
rare in immunocompetent patients. We report an unusual case of Herpes Zoster involving the 
maxillary(V2) and mandibular(V3) branches of the trigeminal nerve in a healthy immunocompetent 
lady.  

Keywords: herpes zoster, neurocutaneous viral infection, trigeminal nerve 

 

Case Presentation 

A 25-year-old lady presented with vesicular lesions with crusts 
on left side of face for 3 days associated with left sided facial 
pain and burning sensation. The lesions began in the left upper 
lip and progressed within the span of 3 days to involve the left 
cheek and chin area, which further spread to involve intraorally. 
There was no facial paralysis, hearing loss or visual symptoms. 
She had no constitutional symptoms. Her past medical history 
was unremarkable.  

General examination of the patient was normal and her vitals 
were stable. Cutaneous examination revealed edema over the 
left side of the face. Multiple grouped maculopapular and 
vesicular lesions were seen over the left lower eyelid, cheek, 
external ear, upper and lower lip, and chin. [Fig 1,2] Intraoral 
examination revealed similar lesions involving left side of hard 
and soft palate and left buccal mucosa. [Fig-3] Ear examination 
revealed vesicles over left pinna. Otherwise, external auditory 
canal and anterior part of the tympanic membrane was normal 
with normal hearing assessment. Ophthalmic examination was 
unremarkable. Facial nerve was intact. The affected areas 
corresponded to the distribution of the left maxillary(V2) and 
mandibular(V3) branches of the trigeminal nerve. Complete 
blood count, serum electrolytes, renal function and blood sugar 
were within normal limits.  

 

 

The patient was started on intravenous Acyclovir 400mg TDS 
for 5 days, followed by T. Acyclovir 400mg QID for another 5 
days. Topical Acyclovir cream, mouth rinse and oral analgesics 
were also prescribed. The patient showed gradual recovery 
with healing of lesions 2 weeks after onset of symptoms.  

 

Figure 1 

                     Open Access                                                                                                                                                                                                               Case Report                                                                           

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Sun et al                                                                                                                                             Asian Journal of Dental and Health Sciences. 2024; 4(1):1-3 

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Figure 2 

 

Figure 3 

Discussion 

Herpes Zoster (HZ), also known as Shingles, is a common viral 
disease caused by reactivation of a latent infection of Varicella 
Zoster Virus(VZV), and alpha herpes virus. After an initial 
infection, the virus remains latent in the perineural satellite 
cells of the dorsal nerve root ganglion.1,2 The frequency of 
zoster in thoracic dermatomes is 53%, cranial nerves is 20%, 
cervical dermatomes is 4-20%, followed by lumbosacral 11%.3 

In HZ, a few lesions can normally appear adjacent to the 
affected dermatome. More extensive skin involvement of 
several adjacent dermatomes is known as multidermatomal 
zoster.4 The ophthalmic branch(V1) of the trigeminal nerve is 
affected about 20 times more often than maxillary(V2) and 
mandibular(V3) branches of the nerve. The maxillary nerve(V2) 
is the least frequently affected branch. It is unusual for zoster to 
involve maxillary(V2) or mandibular(V3) divisions without 
ophthalmic(V1) involvement. Only anecdotal reports exist 
about HZ affecting two or three branches of trigeminal nerve.2,5 
In our patient, the lesions appeared in the area of maxillary(V2) 
and mandibular(V3) nerve distribution, sparing the 
ophthalmic(V1) nerve. In contrast to immunodeficient patients, 
multidermatomal involvement in HZ is rarely observed in 
immunocompetent patients.2 Our case represents a rare 
example of involvement of multidermatomal distribution of HZ 
in a healthy, immunocompetent young lady.  

It has been stipulated that HZ is triggered in part by a decrease 
in immunity. Stress and depressive symptoms are also 
identified as possible trigger of HZ. In conjunction with other 
factors such as age, nutritional status and underlying 
comorbids, stress and psychological symptoms may contribute 
to a lowering of immunity.6 HZ occurs in three successive stages, 
namely prodromal, acute and chronic neuropathic stage.1 The 
prodromal (pre-eruptive stage) presents as pain or dysesthesia 
over the involved nerve distribution associated with mild fever. 
The acute stage is characterized by appearance of an initial 
erythematous macular lesion involving unilateral dermatome, 
that progress into vesiculopapular phase that appears within 1-
2 days and continues to erupt over another 3-4 days.1,3 
Intraoral lesions, when maxillary or mandibular division of 
trigeminal nerve is involved, typically develop after cutaneous 
rash. HZ involving the maxillary nerve (V2) typically present 
with lesions over middle third of the face, lower eyelid, side of 
the nose and upper lip, buccal mucosa and palate; while 
mandibular nerve (V3) involvement is evidenced by lesions 
over the lower third of face, lower lip, temporal region and 
intraoral mucosa. The distribution of vesicles in our patient 
correlated with involvement of maxillary(V2) and 
mandibular(V3) nerves. Chronic neuropathic pain, also known 
as post-herpetic neuralgia, involves around 30% of patients 
with HZ. It is defined as a sharp, intense, radiating pain lasting 
after eruptive stage for about one to three months.7 

In around 16% of patients with HZ, the rash disseminates 
beyond one dermatome, especially in elderly and 
immunocompromised individuals. Only a few cases of 
multidermatomal HZ have been reported in the literature, with 
only a handful number among them occurred in healthy 
immunocompetent individuals.3 Among immunocompetent 
patients, HZ is considered a self-limiting, localized infection. 
Life-threatening and debilitating complications occur almost 
exclusively in immunocompromised patients. These 
complications include encephalitis, herpes zoster ophthalmicus, 
retinitis, delayed contralateral hemiparesis, stroke, and 
myelitis.4 

Early diagnosis and prompt treatment of HZ is the mainstay of 
treatment. Antiviral drugs are best administered within the 
viral replication period, which is ≤72 hours after onset of rash. 
Topical antiviral agents such as Acyclovir cream and docosanol 
cream are also effective. Recommended duration of antiviral is 
7-10 days. Antiviral therapy was shown to be effective in 
shortening the viral shedding period, reducing zoster-
associated pain severity and duration, preventing new lesion 
formation, hastening the healing of skin lesions, and reduction 
in incidence of postherpetic neuralgia.1,5 When vesicles 
postulate, patients are at risk of secondary bacterial infection, 
common organisms being Staphylococcus aureus or 
Streptococcus pyogenes. In secondary infection, oral antibiotic 
is appropriate.8  

A step-wise approach should be taken to treating acute 
neuralgia and post-herpetic neuralgia, according to the severity 
of the patient’s symptoms. Topical analgesics such as capsaicin 
cream and topical lidocaine patch can be used for mild acute 
neuralgia. Tricyclic antidepressants, opioid analgesics and 
gabapentin are commonly used in managing post herpetic 
neuralgia. Gabapentin has been shown to significantly reduce 
the duration of post-herpetic neuralgia.9 In the recent years, the 
use of vitamin C appears to be an emerging treatment for 
attenuating acute neuralgia and post herpetic neuralgia by 
modulating serum levels of cytokine IL-6 and IL-8.10 

Overall incidence rate of HZ is 5.1 per 1000 person years. HZ 
generally is considered to occur only once in a lifetime with 
recurrence limited to immunocompromised individuals. 
However, recurrence rate of 12.0 per 1000 person years among 
immunocompetent persons has been reported.11 Mean time 



Sun et al                                                                                                                                             Asian Journal of Dental and Health Sciences. 2024; 4(1):1-3 

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between initial and recurrent HZ episodes was 1063 days. Risk 
factors for recurrence are elderly age group, women, longer 
duration of post-herpetic immunocompromised status, and 
comorbid conditions.11 Studies have demonstrated that 
immunization of immunocompetent older individuals with live 
attenuated Varicella-Zoster-Virus vaccine reduced the 
incidence and severity of HZ and postherpetic neuralgia. In the 
USA and Canada, the vaccine is recommended for people aged 
≥60 years, whereas in Europe and Australia the vaccine is 
approved for adults aged ≥50 years; inclusive of those who have 
a previous HZ episode and those with underlying chronic 
medical conditions.12 

Our patient was treated with intravenous acyclovir, which was 
converted to oral for a total of 10 days. Topical acyclovir cream 
was also prescribed, along with analgesics and mouth rinse for 
symptomatic relief. The vesicles crusted and healed within 5 
days of initiation of treatment.  

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https://doi.org/10.7860/JCDR/2017/22590.9237
https://doi.org/10.1186/s12895-020-00110-1
https://doi.org/10.4103/0019-5154.135548
https://doi.org/10.4103/0019-5154.135548
https://doi.org/10.4103/2320-3897.195308
https://doi.org/10.1007/s40122-019-0127-z
https://doi.org/10.1086/510206
https://doi.org/10.1155/2020/8857287
https://doi.org/10.3346/jkms.2019.34.e1
https://doi.org/10.1016/S1386-6532(10)70004-4
https://doi.org/10.1016/S1386-6532(10)70004-4

