ACTH versus prednisone and placebo in herpes zoster treatment

Clemmensen, Ole; Andersen, Klaus Ejner

doi:10.1111/j.1365-2230.1984.tb00859.x

Cited by 47 publications

(21 citation statements)

References 12 publications

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“…The risk of PHN and the intractability of pain increases with age. Few children have PHN, whereas 27%, 47%, and 73% of untreated adults over 55, 60, and 70 years of age, respectively, develop PHN (9,12,13). Pain lasting more than 1 year has been reported in 4%, 22%, and 48% of patients less than 20, more than 55, and more than 70 years of age, respectively (8,9).…”

Section: Herpes Zostermentioning

confidence: 99%

Cutaneous infections in the elderly: diagnosis and management

Weinberg

Scheinfeld

2003

Dermatol Ther

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Over the past several years there have been many advances in the diagnosis and treatment of cutaneous infectious diseases. This review focuses on the three major topics of interest in the geriatric population: herpes zoster and postherpetic neuralgia (PHN), onychomycosis, and recent advances in antibacterial therapy. Herpes zoster in adults is caused by reactivation of the varicella-zoster virus (VZV) that causes chickenpox in children. For many years acyclovir was the gold standard of antiviral therapy for the treatment of patients with herpes zoster. Famciclovir and valacyclovir, newer antivirals for herpes zoster, offer less frequent dosing. PHN refers to pain lasting > or = 2 months after an acute attack of herpes zoster. The pain may be constant or intermittent and may occur spontaneously or be caused by seemingly innocuous stimuli such as a light touch. Treatment of established PHN through pharmacologic and nonpharmacologic therapy will be discussed. In addition, therapeutic strategies to prevent PHN will be reviewed. These include the use of oral corticosteroids, nerve blocks, and treatment with standard antiviral therapy. Onychomycosis, or tinea unguium, is caused by dermatophytes in the majority of cases, but can also be caused by Candida and nondermatophyte molds. Onychomycosis is found more frequently in the elderly and in more males than females. There are four types of onychomycosis: distal subungual onychomycosis, proximal subungual onychomycosis, white superficial onychomycosis, and candidal onychomycosis. Over the past several years, new treatments for this disorder have emerged which offer shorter courses of therapy and greater efficacy than previous therapies. The treatment of bacterial skin and skin structure infections in the elderly is an important issue. There has been an alarming increase in the incidence of gram-positive infections, including resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and drug-resistant pneumococci. While vancomycin has been considered the drug of last defense against gram-positive multidrug-resistant bacteria, the late 1980s saw an increase in vancomycin-resistant bacteria, including vancomycin-resistant enterococci (VRE). More recently, strains of vancomycin-intermediate resistant S. aureus (VISA) have been isolated. Gram-positive bacteria, such as S. aureus and Streptococcus pyogenes are often the cause of skin and skin structure infections, ranging from mild pyodermas to complicated infections including postsurgical wound infections, severe carbunculosis, and erysipelas. With limited treatment options, it has become critical to identify antibiotics with novel mechanisms of activity. Several new drugs have emerged as possible therapeutic alternatives, including linezolid and quinupristin/dalfopristin.

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Section: Herpes Zostermentioning

confidence: 99%

Cutaneous infections in the elderly: diagnosis and management

Weinberg

Scheinfeld

2003

Dermatol Ther

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“…In contrast in the results of these studies, 2 Danish studies [61,62] dismissed the use of corticosteroids in herpes zoster based on their results. The first study of 60 patients by Clemmensen and Anderson [61] showed no effect of corticosteroids on healing in the younger population studied (average age 56) and found no significant difference in the number of patients with pain between the corticosteroid group and placebo at 6 weeks. The second study, by Esmann et al, [62] consisted of 78 patients over 60 years old who were all treated with aciclovir.…”

Section: Corticosteroidsmentioning

confidence: 83%

Antiviral Therapy of Acute Herpes Zoster in Older Patients

et al. 1996

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Although herpes zoster (shingles) can occur in anyone with a history of chickenpox, it is more prevalent and usually more severe in older patients (i.e. persons over 50 years of age). While the cutaneous manifestations of shingles usually resolve in approximately 4 weeks, the pain can persist for several months, or even years in the untreated patient. This pain following healing of the skin, termed post-herpetic neuralgia (PHN), can be very severe. Three well tolerated and effective antiviral drugs are available for the therapy of acute herpes zoster. The nucleoside analogues, aciclovir, famciclovir and valaciclovir, appear to shorten the duration of PHN to a similar degree, but none affects the incidence of PHN. Aciclovir is taken 5 times daily for 7 days, while famciclovir is taken 3 times daily for 7 days. Valaciclovir, the L-valyl ester of aciclovir, when taken orally, produces plasma levels of aciclovir equivalent to those seen following intravenous administration of aciclovir. Valaciclovir has not only been proved to be more efficient than aciclovir (i.e. 3 times daily administration) but also more effective than aciclovir in shortening the duration of PHN. Current studies are determining the relative efficacy of valaciclovir versus famciclovir. Presently, a fourth drug, sorivudine, is being compared with aciclovir for the therapy of acute herpes zoster in older patients, but data from these trials are not yet available. Corticosteroids have been used to treat herpes zoster for much longer than the antiviral drugs, but the effect of corticosteroids on PHN does not appear to be consistent. Corticosteroids plus aciclovir did not provide an added benefit over aciclovir alone in one study but this combination did appear to improve the quality of life of older patients in another investigation. The recent availability of the varicella zoster vaccine may cause shingles to be an uncommon and/or mild disease by the mid twenty-first century. Meanwhile, the search continues for more effective and efficient therapies for acute herpes zoster with the primary goal in older patients to affect the most important sequela of zoster in this population, PHN.

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“…[5][6][7][8][9][10][11][12][13] Conclusions from these studies are severely limited, however, due to uncontrolled study design, small sample sizes, variable agents and doses used, and failure to report statistical analysis of the results. In addition, nearly all of the studies excluded patients with comorbid diseases such as hypertension and diabetes mellitus, which are potentially exacerbated by corticosteroids.…”

Section: Clinical Trialsmentioning

confidence: 99%

Oral Corticosteroids for Pain Associated with Herpes Zoster

1998

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It is apparent from published studies that corticosteroids do not prevent the development of postherpetic neuralgia. Earlier trials that indicated some benefit in both acute neuralgia and the prevention of postherpetic neuralgia are of limited use to clinicians due to problems with uncontrolled study designs, small sample sizes, and the absence of statistical analysis of the results. The lack of a consensus definition of postherpetic neuralgia, the variable agents and dosages used, and the different pain scales reported are of concern when trying to interpret the results of these studies for their clinical significance. In more recent larger and well-designed studies, similar rates of postherpetic neuralgia were observed in the corticosteroid and control groups. As a result of these findings, corticosteroids should not be recommended for the prevention of postherpetic neuralgia. Despite lack of efficacy in preventing postherpetic neuralgia, limited studies suggest corticosteroids such as prednisone (40-60 mg/d tapered over 3 wk) are well tolerated and may confer slightly significant benefits in reducing the duration of acute neuralgia and improving quality-of-life measures. However, the clinical significance and application of these findings remain to be addressed. If corticosteroids are used for acute neuralgia, clinicians are advised to select their patients carefully. The patients treated in these studies were generally healthy and free of comorbid diseases, such as hypertension, diabetes mellitus, and psychiatric disorders, which can be exacerbated in the presence of corticosteroids. Although dissemination of herpes zoster has been reported infrequently, it remains a potential risk with use of corticosteroids. Until the results of these studies are repeated in more diverse patient populations, corticosteroids appear to have a limited role in the management of acute neuralgia associated with herpes zoster.

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ACTH versus prednisone and placebo in herpes zoster treatment

Cited by 47 publications

References 12 publications

Cutaneous infections in the elderly: diagnosis and management

Cutaneous infections in the elderly: diagnosis and management

Antiviral Therapy of Acute Herpes Zoster in Older Patients

Oral Corticosteroids for Pain Associated with Herpes Zoster

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