Management of Herpes Zoster and Post-Herpetic Neuralgia

Abstract

Herpes zoster and its sequela post-herpetic neuralgia (PHN) are conditions with significant morbidity. PHN is a chronic, debilitating neuropathic pain that can persist long beyond resolution of visible cutaneous manifestations. This paper provides practical guidelines for management of herpes zoster and PHN. For herpes zoster, antivirals should be started, preferably within 72 h of onset, to reduce the severity and duration of the eruptive phase and to reduce the intensity of acute pain. PHN can be treated with either topical or systemic agents. Topical lidocaine and capsaicin are effective. For patients with more severe pain, the following systemic agents can be considered (in decreasing order of recommendation): the anticonvulsants gabapentin and pregabalin, the tricyclic antidepressants amitriptyline, nortriptyline, and desipramine, and, lastly, the opioid analgesics tramadol, morphine, oxycodone, and methadone. For patients at high risk of developing PHN, early initiation of gabapentin or amitriptyline after the onset of herpes zoster is suggested. The new zoster vaccine has been shown to be effective in reducing the incidence of herpes zoster and PHN.

Randomized placebo-controlled clinical trial showed cold atmospheric argon plasma relieved acute pain and accelerated healing in herpes zoster

“…Acute pain in HZ is regarded as a risk factor for the subsequent development of PHN [1], and meta analyses of current data could not demonstrate any effect on the development of PHN with systemic anti-virals alone [18]. Acute and chronic pain from any cause impacts the daily lives of patients, interferes with sleep, and may cause depression and suicide [19].…”

“…1). The global median incidence of zoster is estimated to be 4-4.5 per 1000 person years, a lifetime risk of 30% [1,2]. Incidence and severity increases with increasing age.…”

“…Antiviral agents shorten the duration of disease and decrease the severity of acute pain but not the risk of postherpetic neuralgia (PHN), defined as pain persisting 4 weeks after healing [3,4]. Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) are the usual first-line analgesics for the acute pain, escalating to tricyclics, anti-convulsants and opioids as clinically indicated [1,5].…”

Effect of corticosteroid therapy in acute pain edema caused by Herpes Zoster

“…Some reported studies have demonstrated that combining corticosteroids with sufficient antivirus treatment can significantly relieve acute pain of herpes zoster and speed up healing of skin lesions, thus improving the quality of life of patients. However, the combinational therapy was not shown to prevent postherpetic neuralgia [10].…”

Management of Pain in the Emergency Department

“…However, all of these agents have side effects and there may be situations in which more targeted analgesia is best. For example, migraine can be treated with a variety of approaches (e.g., triptans, antiemetics, and parenteral valproate), neuralgic conditions may be best treated with agents such as carbamazepine or gabapentin, steroids provide some degree of relief from pharyngitis pain, and calcitonin can improve pain from osteoporotic compression fractures [12][13][14][15][16][17]. Clinicians should not go to undue lengths to avoid use of "broadly active" analgesics, but there should always be consideration as to whether there might be a specific therapy available, that can either replace or reduce the need for agents such as opioids.…”