Acute herpes zoster and postherpetic neuralgia

Abstract

Herpes zoster ( HZ ) is an acute unilateral and segmental inflammation of the dorsal root ganglia caused by infection with the herpes virus varicella-zoster, which also causes chickenpox. During an initial infection of chickenpox, the virus spreads through the blood to the skin and then travels up sensory nerves to the dorsal root ganglia, where a latent infection is established. The virus then lies dormant inside nerve cells near the spinal cord and the brain.It is believed that this virus multiplies as it is reactivated and that it is neutralized by antibodies remaining from initial infection. If effective antibodies are not present [1], which may be the case in older and immunocompromised patients, the virus continues to multiply in the ganglia, destroys the host neuron, and spreads from the sensory nerve to the skin, where it produces a rash and blisters, commonly known as shingles, or herpes zoster. The main problem with this illness is that the pain and discomfort it causes may become chronic. Pain in herpes zoster is very resistant to treatment and remains a source of frustration for both patients and physicians. As the average life expectancy of our population increases, the scope of herpes zoster and its more frequent complication, postherpetic neuralgia (PHN), will expand. Efforts must be made to lessen the tremendous suffering caused by this disease. IncidenceSurveys taken in developed countries suggest that the incidence of HZ ranges from 10% to 20% of the general population, but the percentage increases in patients over 65 years of age and in patients who are immunocompromised by HIV or by the cancer process [2,3]. In those countries or populations in which varicella occurs at a later age, the incidence of HZ is very low, but no data exists to estimate its prevalence.It is commonly believed that a person can develop more than one case of shingles in a lifetime, but this seldom happens because the first attack provides immunity against it. Our focus here is on the large number of patients whose pain continues after the rash has healed, starting a separate and difficult process called postherpetic neuralgia (PHN). It is difficult for several reasons to establish the period of time that elapses before the diagnosis of PHN is appropiate. These reasons include the tendency for pain to lessen after the first 3 to 4 months, the different kinds of pain involved, and the difficulty in treating both pain and patients. Consequently, a good alternative is to observe this approximately 4-month period as defining a PHN process. Prior to this defined period, acute pain of herpes zoster would be a more appropriate diagnosis than PHN [4].The incidence of PHN also increases with age. It is estimated that PHN affects few people under the age of 50, but incidence increases dramatically for patients over the age of 65 (Table 1). A recent meta-analysis indicates that the prevalence of PHN in untreated patients is 25% of that in all patients [5••].As an instance of chronic pain, PHN is treated in many pain clinics, but lit...

The role of stress in the development of herpes zoster and postherpetic neuralgia

“…Neglect of psychologic issues may doom all attempts to measurably improve the life of the patient with herpes zoster or postherpetic neuralgia [23]. [33]; Portenoy [23]; Dworkin and Portenoy [2]; Graff-Radford [5]; Goh [5]; Bowsher [19]; Melzack [26••]; Gasa [27]; Catala and Ferrandiz [1]; Shapiro et al [37,38]; Hekmat [39]; Lohr [41]; Livengood [30,31]; Raj [9]. )…”

“…Family systems therapy is advocated to address added strain on the family system. This therapeutic approach enables family members to provide effective emotional support without inadvertently perpetuating illness behavior [1,9,19,[30][31][32].…”

“…Postherpetic neuralgia, ie, chronic, unrelenting pain persisting in a dermatomal pattern following herpes zoster, is often a debilitating problem for patients and a treatment frustration for physicians [1,2,3••,4-25]. This is not to imply that postherpetic neuralgia is an inevitable outcome of h e r p e s z o s t e r, a s t h e t w o a r e t h o u g h t t o b e separate diseases with different pathophysiologic and clinical aspects [1,15].The purpose of this article is to examine the contribution of psychosocial and physiologic stress in the development of both herpes zoster and postherpetic neuralgia, and to offer treatment suggestions. Whereas health care professionals have little or no control over the patient's stress prior to developing herpes zoster, they can help reduce the patient's emotional and physiologic stress levels after he or she develops herpes zoster and possibly help prevent the development of postherpetic neuralgia.…”

“…Postherpetic neuralgia, ie, chronic, unrelenting pain persisting in a dermatomal pattern following herpes zoster, is often a debilitating problem for patients and a treatment frustration for physicians [1,2,3••,4-25]. This is not to imply that postherpetic neuralgia is an inevitable outcome of h e r p e s z o s t e r, a s t h e t w o a r e t h o u g h t t o b e separate diseases with different pathophysiologic and clinical aspects [1,15].…”