Zoster sine herpete

Facial palsy secondary to herpes zoster virus has traditionally been associated with Ramsay Hunt syndrome (typical cutaneous vesicles and cochleovestibular dysfunction). However vesiculation may not necessarily appear (zoster sine herpete) or may be delayed in up to half of patients

• preherpetic neuralgia (dermatomal pain and dysaesthesia before vesiculation) may be the only clinical indicator that herpes zoster virus is involved
• almost a third of facial palsies previously diagnosed as idiopathic are thought to be due to zoster sine herpete

Treatment is with prednisolone and aciclovir (1)

• 2000 mg/day of aciclovir seems to be effective in patients with zoster sine herpete
• on the basis of current evidence, in the absence of major pain or evidence of vesicles, this dose (2000mg per day) would be adequate with steroids for treating Bell's palsy associated with herpes zoster virus

Reference:

1. Holland NJ, Weiner GM. Recent developments in Bell's palsy.BMJ. 2004 Sep 4;329(7465):553-7