Trigeminal postherpetic neuralgia responsive to treatment with capsaicin 8?% topical patch: a case report

Postherpetic neuralgia has been variably defined but is generally understood to be pain that persists for longer than a few months after an attack of herpes zoster. Pain persists for years in approximately 10 % of those afflicted with acute herpes zoster. The likelihood of postherpetic neuralgia increases with older age, severity of the zoster, trigeminal location, and other factors. Postherpetic neuralgia is a neuropathic pain and treatment usually involves sequential trials of topical and systemic drugs; a variety of other therapies may be considered in refractory cases. A new topical capsaicin 8 % patch has been approved for this indication based on the positive studies in patients with non-trigeminal postherpetic neuralgia. Experience with the use of the capsaicin 8 % patch for trigeminal distribution neuralgia is lacking. We report a case of trigeminal postherpetic neuralgia which was safely and effectively treated with capsaicin 8 % patch.     

17. Herpes Zoster and Post‐Herpetic Neuralgia

Herpes zoster infection is caused by a reactivation of the latent varicella zoster virus that causes chicken pox. It appears predominantly in older adults whose immunity for the virus has waned. The natural course of the disease is usually favorable, and the symptoms disappear spontaneously within a few weeks. Some patients, however, have prolonged pain: post‐herpetic neuralgia. The diagnosis of acute zoster infection is made on the clinical signs including the appearance of rash. Post‐herpetic neuralgia is described as sharp, burning, aching, or shooting constantly present in the dermatome that corresponds with the earlier rash. The objectives of treating herpes zoster are: (1) acute pain reduction; (2) promotion of recovery of epidermal defects and prevention of secondary infections; and (3) reduction or prevention of post‐herpetic neuralgia. The objective of the treatment of post‐herpetic neuralgia is primarily pain alleviation and improvement of the quality of life. Early treatment of the infection and the pain is believed to reduce the risk for post‐herpetic neuralgia. This persistent pain syndrome is difficult to treat. Antiepileptic drugs and tricyclic antidepressants are the first choice. Interventional treatments, such as epidural injections of corticosteroids and local anesthetic drugs, have an effect on the acute pain but are of limited use in preventing post‐herpetic neuralgia. When conservative treatment fails in providing satisfactory relief of post‐herpetic neuralgia, a sympathetic block may be considered (2 C+); if this treatment provides unsatisfactory results, spinal cord stimulation may be considered, in a study context (2 C+). ?     

阿片类药物在慢性非癌性疼痛中的应用

目的:回顾性分析卡马西平和加巴喷丁治疗原发性三叉神经痛、带状疱疹以及带状疱疹后遗神经痛的疗效、安全性和不良反应。方法:102位患者进入本研究,比较卡马西平或加巴喷丁治疗前后患者疼痛强度的改变和对睡眠影响的改善;依据药物分类,比较两种药物的副作用和不良反应。结果:卡马西平治疗原发性三叉神经痛起效较加巴喷丁快,二者长期疗效相当;加巴喷丁治疗带状疱疹和带状疱疹后神经痛的疗效优于卡马西平;疗效随治疗时间的延长而增加。卡马西平的副作用和不良反应事件发生率较加巴喷丁高。结论:抗癫痫药物卡马西平和加巴喷丁是治疗神经病理性疼痛的有效药物,可以改善患者的睡眠,但副作用和不良反应发生率高。     

Herpes zoster: medical and nursing management

Herpes zoster, the latent descendent of the varicella zoster virus, commonly is seen in clinical practice. Healthcare providers must recognize and treat the virus to decrease the incidence of postherpetic neuralgic pain syndrome. Treatment with an antiviral medication regimen should be initiated rapidly for patients who have had lesions for up to 72 hours. Acyclovir has been the treatment of choice for herpes zoster in the past, but newer drugs, such as valacyclovir, a prodrug of acyclovir, and famciclovir, are as effective for treating the virus and have more convenient dosing regimens and decreased incidence of postherpetic neuralgia.     

Herpes zoster and postherpetic neuralgia: prevention and management

Herpes zoster (shingles) is diagnosed clinically by recognition of the distinctive, painful vesicular rash appearing in a unilateral, dermatomal distribution. An estimated 1 million cases occur in the United States each year, and increasing age is the primary risk factor. Laboratory testing, including polymerase chain reaction, can confirm atypical cases. Treatment with acyclovir, famciclovir, or valacyclovir decreases the duration of the rash. Adjunct medications, including opioid analgesics, tricyclic antidepressants, or corticosteroids, may relieve the pain associated with acute herpes zoster. There is conflicting evidence that antiviral therapy during the acute phase prevents postherpetic neuralgia. Postherpetic neuralgia in the cutaneous nerve distribution may last from 30 days to more than six months after the lesions have healed. Evidence supports treating postherpetic neuralgia with tricyclic antidepressants, gabapentin, pregabalin, long-acting opioids, or tramadol; moderate evidence supports the use of capsaicin cream or a lidocaine patch as a second-line agent. Immunization to prevent herpes zoster and postherpetic neuralgia is recommended for most adults 60 years and older.     

The role of sympathetic nerve blocks in herpes zoster and postherpetic neuralgia

The most common complication of herpes zoster in immunocompetent patients is postherpetic neuralgia (PHN). Sympathetic blocks have been traditionally used for patients with herpes zoster and PHN with three different therapeutic goals: pain relief during acute herpes zoster, pain relief during PHN, and prevention of PHN by treating patients with acute zoster. The role of sympathetic blocks in herpes zoster and PHN remains controversial due to methodologic shortcomings in published studies and the limited current understanding of the role of the sympathetic nervous system in mediating pain. Current theories of the pathophysiology of PHN, the role of the sympathetic nervous system in herpes zoster and PHN, and published studies investigating use of sympathetic nerve blocks in herpes zoster and PHN are reviewed.     

Patients' experiences of herpes zoster and postherpetic neuralgia

The purpose of the study was to investigate retrospectively whether patients ( n = 73) who had suffered another disease and/or experienced psychosocial stress at the time of the onset of herpes zoster had experienced a more severe clinical course of herpes zoster, and were more subject to the development of postherpetic neuralgia than other patients ( n =45) with herpes zoster The interview questionnaire included questions about changes in the patients' daily lives due to neuralgia, and their current living circumstances Significantly more of the patients who had had another disease and/or psychosocial stress at the time of the onset of herpes zoster reported severe pain during the acute phase of herpes zoster They also reported pain to a greater extent at the time of the interview and mentioned that their lives had changed owing to postherpetic neuralgia More of these patients reported that their habits and activities had been negatively affected and they also experienced their current situation as unsatisfactory These results must, however, be interpreted with caution as the patients' recollection of other diseases and/or psychosocial stress and the patients' current mood due to postherpetic neuralgia at the time of the interview may have influenced the memory and the answers     

Herpes zoster in older adults. (Duke University Medical Center, Durham, NC) Clinical Infectious Diseases. 2001;32:1481–1486.

Herpes zoster (HZ) strikes millions of older adults annually worldwide and disables a substantial number of them via postherpetic neuralgia (PHN). Key aged‐related clinical, epidemiological, and treatment features of zoster and PHN are reviewed in this article. HZ is caused by renewed replication and spread of the varicella‐zoster virus (VZV) in sensory ganglia and afferent peripheral nerves in the setting of age‐related, disease‐related, and drug‐related decline in cellular immunity to VZV. VZV‐induced neuronal destruction and inflammation causes the principal problems of pain, interference with activities in daily living, and reduced quality of life in elderly patients. Recently, attempts to reduce or eliminate HZ pain have been bolstered by the findings of clinical trials that antiviral agents and corticosteroids are effective treatment for HZ and that tricyclic antidepressants, topical lidocaine, gabapentin, and opiates are effective treatment for PHN. Although these advances have helped, PHN remains a difficult condition to prevent and treat in many elderly patients. Comment by Miles Day, M.D. This article reviews the epidemiology clinical features diagnosis and treatment of acute herpes zoster. It also describes the treatment of postherpetic neuralgia. While this is a good review for the primary care physician, the discussion for the treatment for both acute herpes zoster and postherpetic neuralgia do not mention invasive therapy. It is well documented in pain literature that sympathetic blocks with local anesthetic and steroid as well as subcutaneous infiltration of active zoster lesions not only facilitate the healing of acute herpes zoster but also prevents or helps decrease the incidence of postherpetic neuralgia. All patients who present to the primary care physician with acute herpes zoster should have an immediate referral to a pain management physician for invasive therapy. The treatment of postherpetic neuralgia is a challenging experience both for the patient and the physician. While the treatments that have been discussed in this article are important, other treatments are also available. Regional nerve blocks including intercostal nerve blocks, root sleeve injections, and sympathetic blocks have been used in the past to treat postherpetic neuralgia. If these blocks are helpful, one can proceed with doing crynourlysis of the affected nerves or also radio‐frequency lesioning. Spinal cord stimulation has also been used for those patients who are refractory to noninvasive and invasive therapy. While intrathecal methylprednisolone was shown to be effective in the study quoted in this article one must be cautious not to do multiple intrathecal steroid injections in these patients. Multilple intrathecal steroid injections can lead to archnoiditis secondary to the accumulation of the steroid on the nerve roots and in turn causing worsening pain.     

Management of herpes zoster (shingles) and postherpetic neuralgia

Herpes zoster (commonly referred to as "shingles") and postherpetic neuralgia result from reactivation of the varicella-zoster virus acquired during the primary varicella infection, or chickenpox. Whereas varicella is generally a disease of childhood, herpes zoster and post-herpetic neuralgia become more common with increasing age. Factors that decrease immune function, such as human immunodeficiency virus infection, chemotherapy, malignancies and chronic corticosteroid use, may also increase the risk of developing herpes zoster. Reactivation of latent varicella-zoster virus from dorsal root ganglia is responsible for the classic dermatomal rash and pain that occur with herpes zoster. Burning pain typically precedes the rash by several days and can persist for several months after the rash resolves. With postherpetic neuralgia, a complication of herpes zoster, pain may persist well after resolution of the rash and can be highly debilitating. Herpes zoster is usually treated with orally administered acyclovir. Other antiviral medications include famciclovir and valacyclovir. The antiviral medications are most effective when started within 72 hours after the onset of the rash. The addition of an orally administered corticosteroid can provide modest benefits in reducing the pain of herpes zoster and the incidence of postherpetic neuralgia. Ocular involvement in herpes zoster can lead to rare but serious complications and generally merits referral to an ophthalmologist. Patients with postherpetic neuralgia may require narcotics for adequate pain control. Tricyclic antidepressants or anticonvulsants, often given in low dosages, may help to control neuropathic pain. Capsaicin, lidocaine patches and nerve blocks can also be used in selected patients.     

超激光疼痛治疗仪照射治疗带状疱疹性神经痛的临床研究

应用超激光疼痛治疗仪（Ｓｕｐｅｒ Ｌｉｚｅｒ ＨＡ－５５０，简称ＳＬ）治疗带状疱疹性神经痛病人７０例，其中带状疱疹（ＨＺ）５２例，带状疱疹后神经痛（ＰＨＮ）１８例。疗效以视觉模拟评分法（ＶＡＳ）评价。全组总有效率达８８．６％，疗效与病程有关，而与患者年龄无关。病程≤３个月组显效率明显优于〉３个月组（Ｐ〈０．０１），ＨＺ急性期应用Ｓｕｐｅｒ Ｌｉｚｅｒ照射不仅镇痛效果良好（总有效率９４．２％），而且     

Herpes zoster and postherpetic neuralgia: prevention and management

The recognizable appearance and the dermatomal distribution of herpes zoster lesions usually enable a clinical diagnosis to be made easily. Herpes zoster and postherpetic neuralgia occur mainly in older patients. The role of the varicella vaccine in preventing herpes zoster is uncertain, but is being studied. There is evidence to support using antiviral therapy and possibly low-dose tricyclic antidepressants to prevent postherpetic neuralgia. There is good evidence that treating herpes zoster with antiviral medication is beneficial, particularly in patients older than 50 years with severe outbreaks. The use of steroids has an unfavorable risk-benefit ratio. In patients who develop postherpetic neuralgia, there is good evidence to support treatment with gabapentin and tricyclic antidepressants. More evidence for treatment with capsaicin cream, lidocaine patch, and opioids is needed. Intrathecal methylprednisolone is an option for patients with persistent pain.     

带状疱疹385例临床分析

目的探讨带状疱疹的临床特征、治疗与疱疹后遗神经痛（PHN）的相关性。方法对385例患者的一般资料、临床特点、治疗及临床转归进行回顾性分析。结果男性发病明显多于女性;中老年患者比例为69.4％（267／385）;72例（68.6％）伴有不同程度的白细胞降低和（或）淋巴细胞比例升高。26例发生PHN,发生率为6.75％。结论患者年龄、免疫状况、治疗用药与病程及PHN的发生相关。早期合理用药对缩短病程及防止PHN发生起一定的作用。     

臭氧治疗带状疱疹后遗神经痛临床疗效观察

目的观察臭氧治疗带状疱疹对带状疱疹后遗神经痛发生率的影响。方法 80例急性带状疱疹患者随机分为两组,分别采用传统治疗方法(C组)和传统治疗方法联合臭氧治疗(O组),1年后进行随访,记录带状疱疹后遗神经痛的发生例数。结果治疗7 d后,O组VAS评分明显低于C组,差异具有统计学意义(P0.05)。1年后随访发现C组患者有16例发生带状疱疹后遗神经痛,O组患者只有4例发生了带状疱疹后遗神经痛,O组患者带状疱疹后遗神经痛的发生率低于C组,差异具有统计学意义(P0.05)。结论在传统治疗带状疱疹的基础上联合臭氧治疗,不仅可以有效地减轻带状疱疹神经痛,还可以大大降低带状疱疹后遗神经痛的发生率。     

Postzosterneuralgie

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.     

带状疱疹后神经痛患者疼痛护理研究进展

带状疱疹后神经痛是带状疱疹最常见的并发症,严重影响患者生活质量.本文从带状疱疹后神经痛的概述、临床表现、疼痛评估工具和疼痛护理的研究进展进行综述,以期为临床更有效地帮助带状疱疹后神经痛患者缓解疼痛、提高生活质量提供借鉴和参考.     

Acute herpes zoster and postherpetic neuralgia

Herpes zoster is a common illness in aged patients that is characterized by shingles and severe segmental pain. The nature and duration of the illness is highly variable, and it is also very difficult to relieve. This review of pain in acute herpes zoster and postherpetic neuralgia analyzes clinical observations and describes new treatments that have the potential to improve the lives of patients who suffer from these two illnesses.     

Zoster vaccine to prevent postherpetic neuralgia

In 2006, the U.S. Food and Drug Administration approved the first vaccine for the prevention of acute herpes zoster neuralgia (shingles). This vaccine has important implications in reducing the incidence and severity of the common neuropathic pain condition postherpetic neuralgia. The new vaccine is described.     

Acute pain in herpes zoster: the famciclovir database project

The results of a considerable number of recent prospective studies have demonstrated that greater acute pain severity in herpes zoster patients is associated with a significantly greater risk of developing postherpetic neuralgia (PHN). Only a few studies have examined the relationships between acute pain severity and demographic characteristics and clinical features of patients with herpes zoster, however, and the results of these studies have been inconsistent. To clarify these relationships, data from 1778 herpes zoster patients studied within 72 h of rash onset in four clinical trials of the antiviral agent famciclovir were examined. Univariate and multivariate analyses indicated that greater acute pain severity was significantly associated with greater age, female sex, greater rash severity, the presence of a prodrome, and primary involvement of non-trigeminal dermatomes. These results demonstrate that three of the established risk factors for PHN - older age, greater rash severity, and the presence of a prodrome - are also associated with more severe acute pain assessed soon after rash onset in patients with herpes zoster. The results of this study are consistent with the recommendation that herpes zoster patients who are older, who have had a prodrome, or who have severe rash or severe acute pain should be targeted for interventions designed to prevent PHN.     

Prevention of postherpetic neuralgia: does it exist?

THEORETICAL CONSIDERATIONS: Several pathophysiological mechanisms may be responsible for initiation and maintenance of chronic postherpetic pain. (1) Peripheral nociceptive fibers can develop abnormal sensitization. Secondary to this, central nociceptive "second-order" neurons in the spinal cord dorsal horn can also be sensitized, i.e. they become hyperexcitable and start responding to non-noxious stimuli. (2) Degeneration of nociceptive neurons may trigger anatomical sprouting of low-threshold mechanosensitive terminals to form connections with central nociceptive neurons and may subsequently induce functional synaptic reorganization in the dorsal horn. According to these mechanisms theoretical possibilities of therapeutical interventions to prevent postherpetic neuralgia are (1) adequate analgesia in the acute phase (analgesics, antidepressants, sympathetic blocks) and (2) prevention of C-fiber degeneration by reducing the inflammatory reaction (antiviral drugs, corticosteroids, neurotrophins). CLINICAL EXPERIENCE: The present clinical trials concerning prevention of postherpetic neuralgia were analyzed. Only for the antiviral drugs have valid clinical studies been performed. Using acyclovir a considerable reduction of acute pain and time to healing could clearly be demonstrated. However, there was no significant effect on prevention of postherpetic neuralgia. The second-generation antiviral drugs valaciclovir and famciclovir may be more effective when applied early in the disease course. Preliminary studies indicate that the early onset of therapy with the antidepressant agent amitriptyline may reduce the incidence of postherpetic neuralgia. These results need to be confirmed in further studies. CONCLUSION: Although there is no clear evidence in favor of a prevention of postherpetic neuralgia for any of the interventions, it is definitely reasonable to perform the best analgesia possible during the acute phase of herpes zoster.     

局部紫外线联合阿昔洛韦治疗带状疱疹的疗效观察

目的观察局部紫外线照射联合阿昔洛韦治疗带状疱疹的临床疗效。方法138例带状疱疹患者分为2组。治疗组用阿昔洛韦口服治疗加局部紫外线照射;对照组单用阿昔洛韦治疗带状疱疹。结果治疗组有效率（97．92％）明显高于对照组（P〈0．05）,带状疱疹后遗神经痛发生率亦比对照组明显降低。结论局部紫外线联合阿昔洛韦治疗带状疱疹起效快,疗程短,疗效显著,且能防止后神经痛的发生。