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American Family Physician Nov 2017Herpes zoster, or shingles, is caused by reactivation of varicella zoster virus, which causes chickenpox. There are an estimated 1 million cases in the Unites States... (Review)
Review
Herpes zoster, or shingles, is caused by reactivation of varicella zoster virus, which causes chickenpox. There are an estimated 1 million cases in the Unites States annually, with an individual lifetime risk of 30%. Patients with conditions that decrease cell-mediated immunity are 20 to 100 times more likely to develop herpes zoster. Patients may present with malaise, headache, low-grade fever, and abnormal skin sensations for two to three days before the classic maculopapular rash appears. The rash is usually unilateral, confined to a single dermatome, and typically progresses to clear vesicles that become cloudy and crust over in seven to 10 days. Herpes zoster can be treated with acyclovir, valacyclovir, or famciclovir, ideally within 72 hours of the development of the rash. Postherpetic neuralgia is the most common complication, occurring in about one in five patients. It is defined as pain in a dermatomal distribution sustained for at least 90 days after acute herpes zoster. Treatment is focused on symptom control and includes topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic antidepressants. The varicella zoster virus vaccine decreases the incidence of herpes zoster and is approved for adults 50 years and older. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends this vaccine for adults 60 years and older, except for certain immunosuppressed patients.
Topics: Antiviral Agents; Female; Herpes Zoster; Herpes Zoster Vaccine; Humans; Male; Neuralgia, Postherpetic; Skin
PubMed: 29431387
DOI: No ID Found -
Pain Physician May 2019Postherpetic neuralgia, a persistent pain condition often characterized by allodynia and hyperalgesia, is a deleterious consequence experienced by patients after an...
BACKGROUND
Postherpetic neuralgia, a persistent pain condition often characterized by allodynia and hyperalgesia, is a deleterious consequence experienced by patients after an acute herpes zoster vesicular eruption has healed. The pain associated with postherpetic neuralgia can severely affect a patient's quality of life, quality of sleep, and ability to participate in activities of daily living. Currently, first-line treatments for this condition include the administration of medication therapies such as tricyclic antidepressants, pregabalin, gabapentin, and lidocaine patches, followed by the application of tramadol and capsaicin creams and patches as second- or third-line therapies. As not all patients respond to such conservative options, however, interventional therapies are valuable for those who continue to experience pain.
OBJECTIVE
This review focuses on interventional therapies that have been subjected to randomized controlled trials for the treatment of postherpetic neuralgia, including transcutaneous electrical nerve stimulation; local botulinum toxin A, cobalamin, and triamcinolone injection; intrathecal methylprednisolone and midazolam injection; stellate ganglion block; dorsal root ganglion destruction; and pulsed radiofrequency therapy.
STUDY DESIGN
Systematic review.
SETTING
Hospital department in Taiwan.
METHODS
Search of PubMed database for all randomized controlled trials regarding postherpetic neuralgia that were published before the end of May 2017.
RESULTS
The current evidence is insufficient for determining the single best interventional treatment. Considering invasiveness, price, and safety, the subcutaneous injection of botulinum toxin A or triamcinolone, transcutaneous electrical nerve stimulation, peripheral nerve stimulation, and stellate ganglion block are recommended first, followed by paravertebral block and pulsed radiofrequency. If severe pain persists, spinal cord stimulation could be considered. Given the destructiveness of dorsal root ganglion and adverse events of intrathecal methylprednisolone injection, these interventions should be carried out with great care and only following comprehensive discussion.
LIMITATIONS
Although few adverse effects were reported, these procedures are invasive, and a careful assessment of the risk-benefit ratio should be conducted prior to administration.
CONCLUSION
With the exception of intrathecal methylprednisolone injection for postherpetic neuralgia, the evidence for most interventional procedures used to treat postherpetic neuralgia is Level 2, according to "The Oxford Levels of Evidence 2". Therefore, these modalities have received only grade B recommendations. Despite the lack of a high level of evidence, spinal cord stimulation and peripheral nerve stimulation are possibly useful for the treatment of postherpetic neuralgia.
KEY WORDS
Interventional treatment, postherpetic neuralgia, botulinum toxin, steroid, stellate ganglion block, peripheral nerve stimulation, paravertebral block, radiofrequency, spinal cord stimulation.
Topics: Female; Humans; Male; Neuralgia, Postherpetic; Pain Management; Randomized Controlled Trials as Topic
PubMed: 31151330
DOI: No ID Found -
The New England Journal of Medicine Oct 2014
Review
Topics: Administration, Topical; Aged; Amines; Analgesics, Opioid; Anesthetics, Local; Antipyretics; Capsaicin; Cyclohexanecarboxylic Acids; Female; Gabapentin; Herpes Zoster; Herpes Zoster Vaccine; Humans; Lidocaine; Neuralgia, Postherpetic; Pregabalin; gamma-Aminobutyric Acid
PubMed: 25317872
DOI: 10.1056/NEJMcp1403062 -
Mayo Clinic Proceedings Mar 2009Herpes zoster (HZ), commonly called shingles, is a distinctive syndrome caused by reactivation of varicella zoster virus (VZV). This reactivation occurs when immunity to... (Review)
Review
Herpes zoster (HZ), commonly called shingles, is a distinctive syndrome caused by reactivation of varicella zoster virus (VZV). This reactivation occurs when immunity to VZV declines because of aging or immunosuppression. Herpes zoster can occur at any age but most commonly affects the elderly population. Postherpetic neuralgia (PHN), defined as pain persisting more than 3 months after the rash has healed, is a debilitating and difficult to manage consequence of HZ. The diagnosis of HZ is usually made clinically on the basis of the characteristic appearance of the rash. Early recognition and treatment can reduce acute symptoms and may also reduce PHN. A live, attenuated vaccine aimed at boosting immunity to VZV and reducing the risk of HZ is now available and is recommended for adults older than 60 years. The vaccine has been shown to reduce significantly the incidence of both HZ and PHN. The vaccine is well tolerated, with minor local injection site reactions being the most common adverse event. This review focuses on the clinical manifestations and treatment of HZ and PHN, as well as the appropriate use of the HZ vaccine.
Topics: Administration, Topical; Adrenal Cortex Hormones; Analgesics; Anesthetics, Local; Anticonvulsants; Antidepressive Agents; Antiviral Agents; Herpes Zoster; Herpes Zoster Vaccine; Humans; Lidocaine; Neuralgia, Postherpetic
PubMed: 19252116
DOI: 10.4065/84.3.274 -
BMJ Clinical Evidence Oct 2010Although there is some variability (depending on the definition of postherpetic neuralgia), about 10% of those with zoster will have persisting pain 1 month after the... (Review)
Review
INTRODUCTION
Although there is some variability (depending on the definition of postherpetic neuralgia), about 10% of those with zoster will have persisting pain 1 month after the rash.The main risk factor for postherpetic neuralgia is increasing age; it is uncommon in people aged <50 years, but develops in 20% of people aged 60 to 65 years who have had acute herpes zoster, and in >30% of those people aged >80 years. Up to 2% of people with acute herpes zoster may continue to have postherpetic pain for 5 years or more.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions aimed at preventing herpes zoster and subsequent postherpetic neuralgia? What are the effects of interventions during an acute attack of herpes zoster aimed at preventing postherpetic neuralgia? What are the effects of interventions to relieve established postherpetic neuralgia after the rash has healed? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 41 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: corticosteroids, capsaicin, dextromethorphan, dressings, gabapentin, herpes zoster vaccine, oral antiviral agents, oral opioid analgesics, lidocaine, topical antiviral agents (idoxuridine), and tricyclic antidepressants.
Topics: Antidepressive Agents, Tricyclic; Herpes Zoster; Herpes Zoster Vaccine; Herpesvirus 3, Human; Humans; Neuralgia, Postherpetic
PubMed: 21418680
DOI: No ID Found -
American Family Physician Sep 2011
Review
Topics: Humans; Incidence; Neuralgia, Postherpetic; Prevalence; Prognosis; Risk Factors
PubMed: 21916395
DOI: No ID Found -
Pain Jan 2016Patients with herpes zoster can develop persistent pain after rash healing, a complication known as postherpetic neuralgia. By preventing zoster through vaccination, the... (Meta-Analysis)
Meta-Analysis Review
Patients with herpes zoster can develop persistent pain after rash healing, a complication known as postherpetic neuralgia. By preventing zoster through vaccination, the risk of this common complication is reduced. We searched MEDLINE and Embase for studies assessing risk factors for postherpetic neuralgia, with a view to informing vaccination policy. Nineteen prospective studies were identified. Meta-analysis showed significant increases in the risk of postherpetic neuralgia with clinical features of acute zoster including prodromal pain (summary rate ratio 2.29, 95% confidence interval: 1.42-3.69), severe acute pain (2.23, 1.71-2.92), severe rash (2.63, 1.89-3.66), and ophthalmic involvement (2.51, 1.29-4.86). Older age was significantly associated with postherpetic neuralgia; for individual studies, relative risk estimates per 10-year increase ranged from 1.22 to 3.11. Evidence for differences by gender was conflicting, with considerable between-study heterogeneity. A proportion of studies reported an increased risk of postherpetic neuralgia with severe immunosuppression (studies, n = 3/5) and diabetes mellitus (n = 1/4). Systemic lupus erythematosus, recent trauma, and personality disorder symptoms were associated with postherpetic neuralgia in single studies. No evidence of higher postherpetic neuralgia risk was found with depression (n = 4) or cancer (n = 5). Our review confirms a number of clinical features of acute zoster are risk factors for postherpetic neuralgia. It has also identified a range of possible vaccine-targetable risk factors for postherpetic neuralgia; yet aside from age-associated risks, evidence regarding risk factors to inform zoster vaccination policy is currently limited.
Topics: Age Factors; Herpes Zoster; Humans; Neuralgia, Postherpetic; Risk Factors; Sex Factors
PubMed: 26218719
DOI: 10.1097/j.pain.0000000000000307 -
Journal of Palliative Medicine Sep 2013
Review
Topics: Analgesics; Antidepressive Agents; Humans; Neuralgia, Postherpetic; Pain Management; Palliative Care; Risk Factors
PubMed: 23947632
DOI: 10.1089/jpm.2013.9481 -
Journal Der Deutschen Dermatologischen... Jan 2020The present guidelines are aimed at residents and board-certified specialists in the fields of dermatology, ophthalmology, ENT, pediatrics, neurology, virology,...
The present guidelines are aimed at residents and board-certified specialists in the fields of dermatology, ophthalmology, ENT, pediatrics, neurology, virology, infectious diseases, anesthesiology, general medicine and any other medical specialties involved in the management of patients with herpes zoster. They are also intended as a guide for policymakers and health insurance funds. The guidelines were developed by dermatologists, virologists, ophthalmologists, ENT physicians, neurologists, pediatricians and anesthesiologists/pain specialists using a formal consensus process (S2k). Readers are provided with an overview of the clinical and molecular diagnostic workup, including antigen detection, antibody tests and viral culture. Special diagnostic situations and complicated disease courses are discussed. The authors address general and special aspects of antiviral therapy for herpes zoster and postherpetic neuralgia. Furthermore, the guidelines provide detailed information on pain management including a schematic overview, and they conclude with a discussion of topical treatment options.
Topics: Administration, Topical; Analgesics; Antibodies, Viral; Antiviral Agents; Herpes Zoster; Herpesvirus 3, Human; Humans; Neuralgia, Postherpetic; Pain Management; Risk Factors
PubMed: 31951098
DOI: 10.1111/ddg.14013 -
Schmerz (Berlin, Germany) Feb 2014Postherpetic neuralgia is considered to be a neuropathic pain syndrome. Typically, patients experience pain in the dermatomes of skin lesions persisting for more than 3... (Review)
Review
Postherpetic neuralgia is considered to be a neuropathic pain syndrome. Typically, patients experience pain in the dermatomes of skin lesions persisting for more than 3 months after skin restitution. About 10% of patients with herpes zoster develop postherpetic neuralgia. Its prevalence increases with age. Common clinical symptoms include continuous burning pain, sharp pain attacks, and allodynia. Additionally, sensory hyperactivation or loss in the affected skin area is present. Pathophysiology includes mechanisms of peripheral and central sensitization, based on damaged nerve fibers as the main mechanisms for pain generation and its maintenance. Clinical studies did show pain relief in postherpetic neuralgia after administration of antidepressants, antiepileptic drugs, opioids, and topical capsaicin and lidocaine. Nevertheless, about one third of patients do not respond to conventional treatment. Given the fact that postherpetic neuralgia is considered to be a chronic pain disease, a multidisciplinary treatment approach is necessary.
Topics: Administration, Topical; Aged; Analgesics; Analgesics, Opioid; Anticonvulsants; Antidepressive Agents; Antiviral Agents; Capsaicin; Cooperative Behavior; Cross-Sectional Studies; Herpes Zoster Vaccine; Humans; Interdisciplinary Communication; Lidocaine; Middle Aged; Neuralgia, Postherpetic; Pain Management; Pain Measurement; Randomized Controlled Trials as Topic
PubMed: 24550030
DOI: 10.1007/s00482-013-1346-6