A healthy 56-year-old male was observed in the Family Health Unit presenting a 48-hour history of burning sensation and pain in the palate associated with dysesthesia and facial tenderness restricted to the skin over the right zygomatic bone. No other symptoms were reported. The physical examination revealed a vesicular eruption on the hard palate, on the right side of the midline, compatible with a possible varicella-zoster virus reactivation (Figs. 1 e 2). The patient had previous history of chickenpox, but not shingles. The clinical diagnosis of second branch trigeminal herpes zoster was established, supported by the painful vesicular eruption and sensitivity disturbances confined to the corresponding dermatome of the right maxillary nerve. The alternative diagnosis of herpes simplex infection was considered, however, due to the characteristic unilateral distribution of the oral lesions and to the associated cutaneous facial symptoms on the same dermatome, herpes zoster was accounted as the most likely diagnosis. The patient was treated empirically with oral valacyclovir for one week, which led to complete symptom resolution. Shingles has a lifetime incidence of around 30%,¹ which increases with age, affecting the trigeminal nerve in 20% of cases. ⁽² The first division of the nerve is most commonly involved, causing ophthalmic herpes zoster, whereas the second and third branch involvement are far less common. ⁽³ Maxillary herpes zoster constitutes a rare presentation, especially without a cutaneous rash, and should include the differential diagnosis of ulcerative lesions of the oral mucosa. ^(3,4 It can also present by mimicking odontogenic pain. ^(3,5 Early diagnosis allows rapid treatment initiation, accelerating acute neuritis resolution. ⁽⁶ Postherpetic neuralgia is the main complication of herpes zoster, defined as a persistent neuropathic pain restricted to the affected dermatome after the resolution of the initial symptoms.¹

Figure 1 Vesicular lesions on the hard palate. 

Figure 2 Ampliation of the vesicular lesions on the hard palate.