BRIEF REPORT

A Case of Shingles Following Auricular

Acupuncture

Steven A. Kewish, MD

This is a case report of an occurrence of shingles (herpes zoster [HZ]) following auricular acu-

puncture. The patient developed acute reactivation HZ in the V1 distribution of the right trigeminal

nerve involving the forehead, scalp, and medial upper eyelid 13 days after being treated with au-

ricular acupuncture for chronic low-back pain. The lesions were initially painless, but they clus-

tered and became painful within 2 days. The patient was treated with oral valacyclovir 1000 mg, 3

nique was applied to reduce pain (Figure 1). This

technique calls for the use of 5 semipermanent

needles applied to specific points on 1 or both ears.

The patient recalls the initial Aiguille Semi-Perma-

nente (ASP) needle, placed at the base of the right

intertragic notch (labeled “cingulate gyrus” in Fig-

ure 1), causing a shocklike sensation. Additional

ASP needles were placed bilaterally at the left cin-

gulate gyrus and at the midantitragus (labeled

“thalamus” in Figure 1). None of the subsequent

the patient reported that he began feeling mild

malaise, which he treated with rest. The following

morning he awoke and noticed an area of redness

just below the hairline on the right forehead. As the

day progressed the area became larger, and by the

end of the day, a small cluster of vesicles had ap-

peared. The next morning a second cluster devel-

oped, beginning above the hairline on the right and

extending down in a narrow broken line toward the

medial right eyebrow and terminating near the me-

volvement.

This patient had a history of chicken pox at age

10, no history of herpes zoster (HZ), and had never

received Zostavax or a varicella titer. A detailed

history and physical examination of this patient

revealed no significant acute or chronic medical

conditions, and no other issues predisposing to the

development of shingles.

Standard treatment for HZ was initiated with

valacyclovir, and symptoms were managed with

This article was externally peer reviewed.

Submitted 15 February 2017; revised 18 February 2017;

accepted 21 February 2017.

From the Naval Hospital Bremerton, Bremerton, WA.

Current affiliation: NATO Role 3 Multinational Medical

Unit, Kandahar, Afghanistan.

Funding: none.

Conflict of interest: none declared.

Corresponding author: Steven A. Kewish, MD, Family

Medicine, 1 Boone Road, Bremerton, WA 98312 共E-mail:

tivation. Numerous other potential side effects are

known; however, only 1 primary source document

was located showing an association between acu-

puncture and herpes.

A literature review noted

several cases of trauma-induced trigeminal nerve

zoster, but none were specifically associated with

auricular acupuncture (Figures 1–3).

Discussion

virus reactivates and travels to the dermatome

corresponding to its nucleus or ganglion, pro-

ducing the typical painful, vesicular rash of shin-

gles. Recurrence can happen at different ages and

in different locations in the same person. Typi-

cally, however, subsequent cases are progres-

sively less common. Precipitating factors for

shingles include stress, trauma, chronic disease,

systemic illness, and immune disorders, among

others.

50 years and older, the Centers for Disease Con-

trol and Prevention recommend routine vaccina-

tion starting at age 60, largely because of the

limited vaccine supply and a lower incidence of

postherpetic neuralgia among people in their 50s

(based on the Centers for Disease Control and

Prevention and Advisory Committee of Immuni-

zation Practices 2014 guidelines).

Acupuncture is a procedure that represents a

minor trauma. Physical trauma and surgical proce-

trauma in HZ cases compared with controls in any of

the 52 weeks before the onset of symptoms; the

greatest proportion occurred in the first week. In

addition, patients diagnosed with cranial HZ were

⬎25 times as likely as controls to have had cranial

trauma during the week before HZ onset.

control study by Thomas et al

Figure 1. Approximate needle insertion sites for

Battlefield Acupuncture.

Figure 2. Shingles in the V1 distribution of the

Trigeminal Nerve.

tion of nerve nuclei or ganglia is proposed. The

literature suggests that outbreaks are most likely

to occur within the first month after the insult.

Although cause and effect cannot be proven in

this case, the timing, mechanism, and proximity

to the acupuncture “trauma” are compelling. The

Figure 3. Anatomy of the Trigeminal Nerve.