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post Herpetic neuralgia

Dermatomal pain persisting at least 90 days after the appearance of the acute herpes zoster rash [10] Etiology: - Herpes zoster - risk factors - immunosuppression* - systemic lupus erythematosus [15] * 2-fold increased risk in patients with lymphoma, leukemia, or myeloma or recent glucocorticoid use [15] Epidemiology: - risk increases with age - annual incidencs is 0.34% at age 50 & 1.1% at age 90 [9] - recurrence is <6% among immunocompetent individuals [9] Clinical manifestations: - persistent radicular pain after resolution of rash that occurs with shingles (Herpes zoster) - occurs in the same dermatome as the index case of shingles - may be severe & continue for months Management: 1) gabapentin (Neurontin) [3] {treatment of choice [4,6]} a) start 300 mg PO QD; 100 mg PO QHS in elderly [4] b) 300 mg BID on day 2 c) 300 mg TID on day 3 d) titrate up to 600 mg TID (no evidence higher doses more effective) e) improves sleep, pain, quality of life 2) pregabalin also effective 3) tricyclic antidepressants 4) transcutaneous electrical nerve stimulation (TENS) 5) topical capsaicin, topical lidocaine - treatment of choice in the elderly [16] 6) famciclovir (Famvir) 500 mg TID for 7 days 7) intrathecal or epidural methylprednisolone plus lidocaine or bupivacaine weekly [2]; 7-21 days [5] - a single epidural injection methylprednisolone plus bupivicaine not effective [5] 8) investigational angiotensin 2 receptor-2 antagonist EMA401 may be useful for treating postherpetic neuralgia [8] 9) opiates, short term or as a last resort in refractory cases [9] - consultation with pain-management specialist may be prudent 10) prognosis: - < 50% of patients report > 50% reduction in pain [9] - adverse effect of treatment are common, especially in elderly [9] 11) prevention: - Herpes zoster vaccine significantly reduces the incidence of both herpes zoster & postherpetic neuralgia, although the number needed to treat to prevent 1 case is 11 & 43, respectively (at best, see Herpes virus vaccine) - antivirals of no benefit in prevention of postherpetic neuralgia [11] - glucocorticoids of uncertain benefit in prevention of postherpetic neuralgia [12,17]

Related

Herpes zoster (shingles)

General

Herpes zoster with neurologic complications peripheral nerve disease; peripheral neuropathy neuralgia

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 866
  2. Journal Watch 21(1):10, 2001 Kotani et al N Engl J Med 343:1514, 2000
  3. Prescriber's Letter 9(7):39 2002
  4. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  5. van Wijck AJ, Opstelten W, Moons KG, van Essen GA, Stolker RJ, Kalkman CJ, Verheij TJ. The PINE study of epidural steroids and local anaesthetics to prevent postherpetic neuralgia: a randomised controlled trial. Lancet. 2006 Jan 21;367(9506):219-24. PMID: 16427490 - Baron R, Wasner G. Prevention and treatment of postherpetic neuralgia. Lancet. 2006 Jan 21;367(9506):186-8. No abstract available. PMID: 16427472
  6. Lapolla W et al. Incidence of postherpetic neuralgia after combination treatment with gabapentin and valacyclovir in patients with acute herpes zoster: Open-label study. Arch Dermatol 2011 Aug; 147:901. PMID: 21482862
  7. Whitley RJ, Volpi A, McKendrick M, Wijck Av, Oaklander AL. Management of herpes zoster and post-herpetic neuralgia now and in the future. J Clin Virol. 2010 May;48 Suppl 1:S20-8 PMID: 20510264
  8. Rice AS et al EMA401, an orally administered highly selective angiotensin II type 2 receptor antagonist, as a novel treatment for postherpetic neuralgia: a randomised, double-blind, placebo- controlled phase 2 clinical trial. The Lancet, Early Online Publication, 5 February 2014 PMID: 24507377 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2962337-5/abstract
  9. Johnson RW, Rice AS Postherpetic Neuralgia N Engl J Med 2014; 371:1526-1533 PMID: 25317872 http://www.nejm.org/doi/full/10.1056/NEJMcp1403062
  10. Fazio S Postherpetic Neuralgia Now@NEJM. Oct 17, 2014 http://blogs.nejm.org/now/index.php/postherpetic-neuralgia/2014/10/17/
  11. The NNT: Antiviral (Anti-herpes virus) Medications for the Prevention of Post-Herpetic Neuralgia. http://www.thennt.com/nnt/antivirals-for-preventing-post-herpetic-neuralgia/ - Li Q, Chen N, Yang J, Zhou M, Zhou D, Zhang Q, He L. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD006866 PMID: 19370655
  12. The NNT: Corticosteroids for the Prevention of Post-Herpetic Neuralgia. http://www.thennt.com/nnt/corticosteroids-for-preventing-post-herpetic-neuralgia/ - He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005582 PMID: 18254083
  13. Dubinsky RM, Kabbani H, El-Chami Z et al Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004 Sep 28;63(6):959-65. Review. PMID: 15452284
  14. Argoff CE. Review of current guidelines on the care of postherpetic neuralgia. Postgrad Med. 2011 Sep;123(5):134-42. Review. PMID: 21904096
  15. Forbes HJ, Bhaskaran K, Thomas SL et al. Quantification of risk factors for postherpetic neuralgia in herpes zoster patients: A cohort study. Neurology 2016 Jul 5; 87:94 PMID: 27287218 http://www.neurology.org/content/87/1/94
  16. Medical Knowledge Self Assessment Program (MKSAP) 17, 18 American College of Physicians, Philadelphia 2015, 2018.
  17. Jiang X, Li Y, Chen N, Zhou M, He L. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2023 Dec 5;12(12):CD005582. PMID: 38050854 Review.