Unusual herpetic reactivation in a young female following botox injection: a case report study

**Background:** Botulinum toxin (Botox) injections are widely used for cosmetic wrinkle reduction and various medical conditions. While generally safe, rare complications include herpetic reactivation. Varicella-zoster virus (VZV) causes chickenpox and then becomes latent; reactivation leads to herpes zoster (shingles). The association between Botox and herpes reactivation is poorly documented, with only a few case reports in the literature. This paper presents a case of herpes zoster following cosmetic Botox injection in a young, healthy woman.

**Methods:** This is a single case report. A 33-year-old woman presented to the hospital on March 23, 2023, five days after receiving cosmetic Botox injections into her forehead lines, crow’s feet, and glabellar frown lines. She had a history of chickenpox at age 8 but no other medical conditions, medications, allergies, or surgeries. Within 24 hours of injection, she experienced pain and burning in the injected areas. Over the next four days, she developed progressive vesiculopustular lesions on the right frontal region, fever, chills, and preorbital inflammation and edema. On day five, a Tzanck smear test was performed, which showed multinucleated giant cells suggestive of herpetic infection. An HIV antibody test was negative. The patient was started on intravenous acyclovir and followed for clinical improvement.

**Key Results:** The Tzanck smear was positive for herpetic infection. HIV testing was negative. After initiation of intravenous acyclovir, the vesiculopustular lesions gradually regressed and became crusted over the following days. Preorbital edema improved. The patient’s fever, chills, and pain resolved. The paper includes a table summarizing previous reports of herpes zoster following Botox injections: de Souza et al. (43-year-old woman, cosmetic injection, no risk factors), Farahmand et al. (68-year-old, blepharospasm treatment, old age and hypertension, developed encephalitis), Gadient et al. (72-year-old, migraine treatment, old age and previous herpes zoster, minor dysesthesia), Graber et al. (two patients aged 55 and 48, cosmetic injection, no risk factors; one had persistent subacute headache), Muzumdar et al. (25-year-old, axillary hyperhidrosis, no risk factors), Ramappa et al. (55-year-old, eyelid disorder, previous viral keratitis, corneal abrasions), and Narang et al. (59-year-old, lacrimal gland injection for epiphora, previous herpes simplex keratitis, watering and ptosis).

**Clinical Implications:** This case highlights that herpetic reactivation can occur after Botox injection even in young, immunocompetent individuals, and can present within 24 hours—earlier than previously reported (typically one week). The authors hypothesize that Botox complex proteins may act as antigens, leading to T cell exhaustion via sustained expression of the transcription factor TOX, which downregulates CD4+ and CD8+ T cells and reduces cytokines (TNF-α, IL-6, IFN-α) that normally suppress VZV. Clinicians performing cosmetic injections should be aware of this potential complication and educate patients about the risk. Early diagnosis with Tzanck smear or PCR and prompt initiation of antiviral therapy (e.g., acyclovir) are crucial to prevent progression and complications such as postherpetic neuralgia, encephalitis, or bacterial superinfection. The authors also recommend HIV testing in patients presenting with dermatological herpes to rule out acquired immunodeficiency. Limitations include the single-case design, lack of long-term follow-up, absence of ophthalmology consultation, and unknown Botox brand/quality. Further cross-sectional and meta-analysis studies are needed to establish causality and risk factors.