Zoster Pain Research Articles

Impact of Underlying Conditions on Zoster-Related Pain and on Quality of Life Following Zoster.

Background:Chronic conditions have been investigated as risk factors for developing zoster, but in patients suffering from zoster, the impact of underlying conditions in zoster-related pain and quality of life (QOL) remains unclear.Methods:We performed a post hoc analysis of a prospective cohort study in immunocompetent zoster patients aged 50 years or older, conducted by general practitioners in Italy between 2009 and 2010. Zoster symptoms, pain intensity and characteristics, and physical and mental health scores were assessed at baseline (zoster diagnosis) and at 1, 3, and 6 months of follow-up.Results:Among 413 patients enrolled in the study, 73% (303/413) suffered from underlying conditions of which 69% (209/303) were aged 65 or older. Cardiovascular diseases (75%), diabetes (24%), and respiratory diseases (17%) were most frequent. One to three months after onset, zoster patients with underlying conditions experienced more intense zoster-related pain than those without. QOL scores were significantly lower in patients with underlying conditions, and age-adjusted difference in QOL scores between the groups increased over time, demonstrating a slower recovery for patients with underlying conditions.Conclusions:In addition to age, the main risk factor of zoster occurrence and severity, the presence of underlying conditions results in more painful and impactful zoster episodes, creating a significant burden for these patients.

Effect of Repetitive Intracutaneous Injections with Local Anesthetics and Steroids for Acute Thoracic Herpes Zoster and Incidence of Postherpetic Neuralgia.

Treatment of established postherpetic neuralgia (PHN) is difficult and often disappointing. In this study, we assessed the efficacy of repetitive intracutaneous injections with local anesthetics and steroids in acute thoracic herpes zoster (HZ) pain, herpetic eruption, and incidence of PHN. Ninety-three patients with acute thoracic HZ were randomly assigned to receive a standard treatment of antiviral medication with p.o. analgesics or the standard treatment with the addition of repetitive intracutaneous injections of a local anesthetic and steroid mixture. Patients were permitted to take tramadol when the visual analog scale (VAS) ≥ 4. Pain assessment using VAS was conducted at the initial visit, as well as 1, 2, 4, 12, and 24 weeks after the end of the treatments. In comparison with the standard treatment group, the VAS scores of the intracutaneous injection group were significantly lower during the study. The intracutaneous injection group also reported shorter duration of pain and skin eruption than the control group ( P = 0.005 vs P < 0.001, respectively). At 1 month post-therapy, 12.8% patients in the intracutaneous injection group reported zoster-associated pain, compared with 47.8% in the standard treatment group ( P < 0.001). At 3 and 6 months post-therapy, the incidence of PHN was still significantly lower in the intracutaneous injection group than the standard treatment group. EuroQol VAS scores were significantly higher in the intracutaneous injection group vs standard treatment group (P < 0.001). Repetitive intracutaneous injections with local anesthetics and steroids along with standard treatment significantly reduce the duration of pain and herpetic eruption and incidence of PHN.

Retrospective analysis of foscarnet sodium combined with valacyclovir in the treatment of acute pain in herpes zoster

Objective To investigate the clinical curative effect and impact factors of valaciclovir and foscarnet sodium combination therapy on zoster patients who suffered from acute neuralgia. Methods The hospitalization information of 139 herpes zoster patients suffered from acute neuralgia was collected who enrolled in Department of Dermatology, the Second Xiangya Hospital of Central South University between Jan. 1st, 2015 to Dec. 31st, 2015. Their general condition, symptoms, signs and parameters of curative effect evaluation were recorded, including the time days for control rash, rash relief, rash diminish, the pain began to relief and the pain obvious relief. A retrospective cohort study was carried out to analyze the above information. Results The ratio of men to women who were hospitalized because of herpes zoster was 1.07∶1. The rash mostly occurred on head, face and trunk. A percentage (92.8%) of the patients was suffered from basic disease. The curative effect evaluation: the average days for control rash were (2.32 ± 1.10) d. The average days for rash relief were (5.80 ± 2.27) d. The average days for pain began to relief were (3.14 ± 1.32) d. The average days for pain obvious relief were (6.86 ± 2.30) d. The curative effect of patient under the age of 60 was significantly better than the older (P<0.01). The patient with hypoproteinemia showed poorer curative effect compared to patients without hypoproteinemia (P<0.05). The curative effect among patients with more than 3 kinds of diseases was significantly lower than patients with less than 3 kinds of disease (P<0.05). Conclusions The valaciclovir and foscarnet sodium combination therapy displayed definite curative effect on the herpes zoster patients who suffered from acute neuralgia. There are no significant differences among genders in terms of pain relief. The age, serum albumin levels and accompanied diseases were the impact factors for pain relief. Key words: Acyclovir/AA/AD; Foscarnet/AD; Neuralgia, postherpetic/DT

Epidemiology of Postherpetic Neuralgia in Korea: An Electronic Population Health Insurance System Based Study.

Postherpetic neuralgia (PHN) is a disease entity defined as persistent pain after the acute pain of herpes zoster gradually resolves. It is associated with impaired daily activities, resulting in reduced quality of life. General epidemiological data on PHN is necessary for the effective management. However, data on the epidemiology of PHN in Korea is lacking. The aim of this study was to evaluate the epidemiological features of PHN in the general population.We used population-based medical data for 51,448,491 subscribers to the Health Insurance Service in the year of 2013 to analyze of PHN epidemiology in Korea, such as the incidence, regional distribution, seasonal variation, and healthcare resource utilization. Total number of patients and medical cost on PHN were analyzed from 2009 to 2013.Findings indicate that the incidence of PHN in Korea was 2.5 per 1000 person-years, which was strongly correlated with age and sex. There were no differences in seasonal variation or regional distribution. The medical cost increased steadily over the study period. When admitted to general hospitals, patients with PHN were mainly managed in the dermatology and anesthesiology departments.The incidence and prevalence rates of PHN in Koreans appear to be considerably higher compared to those in western populations, while the sex and age predisposition was similar. Considering that the pain associated with PHN can have a marked impact on a patient's quality of life resulting in a medicosocial economic burden, anesthesiology physicians have an important role in primary care in Korea. Future research on the cost-effectiveness of the management of PHN is needed.

Pre-Existing Chronic Pain Influences the Severity of Acute Herpes Zoster Pain-A Prospective Observational Cohort Study.

Pre-existing chronic pain has been associated with severe postoperative pain. To analyze the impact of chronic pain on non-surgical acute pain, a cohort of patients with acute herpes zoster was studied. Consecutive patients, who needed hospitalization because of an acute zoster infection, were characterized and compared according to their pain history. Pain intensity, pain-related function, analgesic consumption, and psychological and physiological characteristics were assessed as baseline parameters on the day of hospitalization. Pain intensity and functional restrictions were evaluated on day 1, 4, 7, and on the day of discharge. The analgesic consumption was recorded and scored for each of these days. A multivariate analysis was performed for individual predictors. 59 patients were included; 25 patients (42.4%) had pre-existing chronic pain. These patients had more severe acute zoster pain on all assessment days and were more restricted in function, such as sleep quality and mobilization. There were, however, no differences in analgesic consumption. In patients without chronic pain, only the amount of analgesic consumption was associated with the severity of zoster pain. In contrast, in patients with chronic pain, the severity of the chronic pain, physical health, and the extent of neuropathic pain characteristics were associated with the intensity of zoster-related acute pain, while analgesic consumption was not. Patients with chronic pain had higher intensity of zoster-related acute pain. Furthermore, they showed more pain-related dysfunction and needed longer hospitalization than patients without chronic pain. These results go along with findings for acute postoperative pain.

Prednisolone can Prevent Post-Herpetic Neuralgia in Post-Kidney Transplant Recipient

Background and study aim: Post-herpetic neuralgia (PHN) is a neuropathic painful condition that is one of the most frequent complications of an acute herpes zoster infection. Till now, there is no general agreement on the definition of PHN. Some studies described a wide range of definitions, including any pain that comes after disappearing of the herpes zoster rash, whereas other studies applied the definition of pain that persist for more than one or two months after the onset of rash. The aim of this study was to assess the effect of oral prednisolone with antiviral therapy on prevention of post-herpetic neuralgia in post-kidney transplant recipient. Patients and methods: 40 patients were divided into two groups, the first one (group A) involved 20 patients who had renal transplant within the past five years and have received oral prednisolone (10 mg/day) and the second one (group B) involved also 20 patients but they are immune-competent without co-morbidity. Follow up was done at one, three and six months to assess the pain. Results: At time of admission and discharge, there was significant difference between group A and group B as regard zoster pain. The same significance was observed between two groups during follow up after one and three months and not observed after six months. Conclusion: Oral corticosteroid can promote modest benefits in decreasing the pain of herpes zoster and the incidence of PHN in post-kidney transplant recipient.

Transient Receptor Potential Vanilloid-1 in Epidermal Keratinocytes May Contribute to Acute Pain in Herpes Zoster.

The role of transient receptor potential vanilloid-1 (TRPV1) in the initiation of neurogenic inflammation and transduction of pain is well established. In this study 33 patients with herpes zoster (HZ) were recruited from a single centre and underwent a questionnaire interview at their first visit. Punch biopsies from the HZ lesions and the contralateral unaffected skin were performed to localize and quantify the expression of TRPV1. Immunofluorescent staining for TRPV1 was most prominent in the epidermal keratinocytes. Both TRPV1 mRNA and protein levels were significantly higher in the HZ epidermis than in control epidermis (relative ratio 1.62 ± 0.27, p = 0.033 and 2.55 ± 0.51, p = 0.005, respectively). Protein TRPV1 ratio (HZ lesion/control) correlated with the degree of pain (measured on a visual analogue scale; VAS) (p = 0.017) and was significantly lower in patients who had taken either HZ medication or painkillers prior to their visit. These results suggest that non-neuronal TRPV1 may contribute to acute pain in herpes zoster.

A Study of Intravenous Administration of Vitamin C in the Treatment of Acute Herpetic Pain and Postherpetic Neuralgia.

BackgroundAlthough there are several available management strategies for treatment of both acute pain of herpes zoster (HZ) and postherpetic neuralgia (PHN), it is difficult to treat them adequately.ObjectiveThe aim of this study was to evaluate the efficacy of intravenously administrated vitamin C on acute pain and its preventive effects on PHN in patients with HZ.MethodsBetween September 2011 and May 2013 eighty-seven patients who were admitted for HZ were assessed according to age, sex, underlying diseases, duration of pain and skin lesion, dermatomal distribution, and PHN. It was a randomized controlled study, in which 87 patients were randomly allocated into the ascorbic acid group and control group. Each patient received normal saline infusion with or without 5 g of ascorbic acid on days 1, 3, and 5 then answered questionnaires that included side effects and pain severity using visual analogue scale on days 1, 2, 3, 4, and 5. After discharge, the severity of pain was obtained at out-patient clinic or by telephone on weeks 2, 4, 8, and 16.ResultsThere was no differences in severity of pain on patients' age, sex, underlying diseases, duration of pain and skin lesion and dermatomal distribution between two groups (p>0.05). Since 8th week, pain score in ascorbic acid treatment group was significantly lower than control group (p <0.05). The incidence of PHN was significantly lower in the treatment group compared to control group (p=0.014). The changes of overall pain score was significantly different between the two groups (p<0.05).ConclusionIntravenously administered ascorbic acid did not relieve acute HZ pain; but is effective for reducing the incidence of PHN.

What is the best treatment for the acute pain of herpes zoster?

What is the best treatment for the acute pain of herpes zoster?

Reducing pain in acute herpes zoster with plain occlusive dressings: a case report

IntroductionThe pain of acute herpes zoster (shingles) is severe and difficult to control. The medications used to control pain have a variety of important and potentially serious side effects. To the best of my knowledge, this is the first case report of using a plain topical occlusive dressing to reduce the pain of herpes zoster, avoiding the use of medication.Case presentationA 40-year-old Caucasian man and a qualified physician (the author), developed a dermatomal vesicular rash consistent with herpes zoster. Applying plain topical occlusive dressings reduced the severity of his pain to an ignorable level.ConclusionPlain topical occlusive dressings provide effective pain relief for acute herpes zoster, thereby avoiding the risks accompanying medication use.

Predictors of postherpetic neuralgia in patients with herpes zoster: a pooled analysis of prospective cohort studies from North and Latin America and Asia

The most common complication of herpes zoster (HZ) is postherpetic neuralgia (PHN), a persistent pain that can substantially affect quality of life (QoL). This analysis aimed to evaluate predictors of PHN in HZ patients. A pooled analysis of prospective cohort studies of HZ patients aged ≥ 50 years from North America (Canada), Latin America (Brazil, Mexico, and Argentina), and Asia (Taiwan, South Korea, and Thailand) was performed. Patients within 14 days of rash onset were included. The incidence of PHN was defined as a worst pain score of ≥ 3, persisting/appearing at >90 days after rash onset. Socio-demographics, HZ disease characteristics, treatment, pain-related interference with activities of daily living, and health-related QoL were assessed. Of 702 patients with HZ, 148 (21.1%) developed PHN. Similar risks of PHN were observed across geographic regions. On multivariate analysis, older age, greater severity of pain at rash onset, employment status, walking problems at enrollment, and pain interference affecting social relationships were significantly associated with the development of PHN. In addition to older age and severe acute pain, this study suggests that impaired physical and social functioning from acute zoster pain may play a role in the development of PHN in this prospective cohort study of HZ patients from North and Latin America and Asia.

Relief of intractable electric shock-like subacute zoster pain by valproic acid in three patients who underwent blood stem cell transplantation

Relief of intractable electric shock-like subacute zoster pain by valproic acid in three patients who underwent blood stem cell transplantation

Increasing engagement of clinicians in adult immunizations: Reflections on a decade and a half of research

Increasing engagement of clinicians in adult immunizations: Reflections on a decade and a half of research

Incidence of herpes zoster and persistent post-zoster pain in adults with or without diabetes in the United States.

This study was designed to assess the association between diabetes and herpes zoster (HZ) and persistent post-zoster pain (PPZP). We used a United States-based, 2005-2009 retrospective observational study of medical and pharmacy claims from adults in 3 large national databases. Incidence rate ratios were used to compare HZ incidence by diabetes status. Multivariate regressions assessed the age and sex-adjusted risk of diabetes on HZ and PPZP as a function of immune competence. National projections of HZ and PPZP cases were obtained. Among 51 million enrollees (∼88 million person-years [PYs] at risk), we identified 420 515 HZ cases. Patients with diabetes represented 8.7% of the PYs analyzed but accounted for 14.5% of the HZ cases and 20.3% of the PPZP cases. The crude incidence of HZ was 78% higher (7.96 vs 4.48 cases/1000 PY; P < .01) and the rate of PPZP was 50% higher (5.97% vs 3.93%; P < .01) in individuals with diabetes than without. Individuals with diabetes had 45% higher adjusted risk of HZ (hazard ratio [HR] = 1.45; 95% confidence intervals [CIs], 1.43-1.46) and 18% higher adjusted odds of PPZP (odds ratio = 1.18; 95% CI, 1.13-1.24). The risk of HZ associated with diabetes among immune-compromised individuals was weaker (HR = 1.10; 95% CI, 1.07-1.14) and the risk of PPZP was no longer significant. Every year, approximately 1.2 million HZ cases occur in US adults, 13% of these occur in individuals with diabetes. Diabetes is a risk factor for HZ and PPZP in the US adult population. This association is stronger in immune-competent individuals.

Superficial cervical plexus block for management of herpes zoster neuralgia in the C3 dermatome: a case report

IntroductionHerpes zoster is a well-known reactivating viral disease that gives rise to painful skin lesions. Although this vesicular rash heals up within a few weeks, pain sometimes continues, becoming postherpetic neuralgia. In the case of those at high risk of developing postherpetic neuralgia, early interventional pain management is generally recommended as a preventive measure. Pain specialists usually do not see patients face-to-face for chronic refractory pain until the stage of postherpetic neuralgia. However, active and aggressive management, including antiviral treatment, of herpetic neuralgia during the acute stage of herpes zoster promises better results. In this respect, superficial cervical plexus block can help patients, such as the case reported here, by relieving the pain of herpes zoster involving the C3 dermatome.Case presentationA 65-year-old Korean man with severe pain in his left C3 dermatome due to herpes zoster was admitted to our hospital. His pain was so refractory to medication that he consulted our pain clinic for pain control. Due to the medication limitations imposed by his underlying diseases (hepatitis B, liver cirrhosis, atrial fibrillation, and asthma), early interventional therapy including stellate ganglion block was planned. In addition, because his painful C3 dermatome overlapped significantly with the superficial cervical plexus dermatome, ultrasound-guided superficial cervical plexus block was utilized for pain control of the intractable herpes zoster neuritis in his C3 dermatome. The result with respect to his sporadic neuralgia was satisfactory.ConclusionsWe found superficial cervical plexus block to be an effective interventional procedure for pain management of herpes zoster, particularly at the C3-dermatomal level.

Single Paravertebral Injection for Acute Thoracic Herpes Zoster: A Randomized Controlled Trial

The aim of this study was to evaluate the efficacy of single thoracic paravertebral injection in acute thoracic herpes zoster (HZ) pain, eruptive duration, and the incidence of postherpetic neuralgia (PHN). One hundred thirty-eight patients over 50years of age with acute thoracic herpetic eruption were randomly assigned to receive a paravertebral block using either 10mL saline (placebo group) or 25mg bupivacaine, plus 8mg dexamethasone in a total volume of 10mL (active group). All the patients received pregabalin 150mg twice daily. Acetaminophen was available as rescue analgesia. Pain severity was assessed using visual analog scale (VAS). Analgesics consumption was evaluated weekly. Time to pain resolution, healing of the skin eruption, and incidence of persistent postherpetic pain were reported. Significantly shorter duration of pain and herpetic eruption was noticed in the active group vs. placebo group (P=0.013 and <0.001, respectively). Active group showed significantly lower VAS at the third week. Significantly lower doses of pregabalin and acetaminophen were consumed in the active group. Incidence of PHN was comparable in both groups after 3months (P=0.094). A significantly lower incidence of PHN was noted in active treatment group at 6months (P=0.048). Early single paravertebral blockade in the course of acute thoracic HZ seems to be a safe and effective adjuvant treatment modality.

The effect of ketamine as an additive in epidural block on the intractable herpetic neuralgia: a case report

Ketamine has been shown to have analgesic effect by blocking N-methyl-D-aspartate receptor, thus preventing and reducing central sensitization caused by peripheral nociceptive stimulation. However, due to lack of knowledge about its safety and toxicity in the central nervous system, either epidural or intrathecal injection of ketamine still remains controversial. Here, we describe a case report of satisfactory pain relief after the addition of ketamine in epidural injection in a patient with severe herpes zoster pain that was refractory to conventional medication, intravenous opioids and continuous epidural block. This case indicates the viability of epidural ketamine injection in patients with intractable herpetic neuralgia.

Cervical epidural infusion for the treatment of herpes zoster pain. Case report with review of the literature

IntroductionHerpes zoster is caused by a reactivation of the varicella zoster virus. Clinically, the disease manifests with pain in the area of a dermatome associated with vesicular exanthema. The most common complication is post-herpetic neuralgia, more frequent among elderly patients. The treatment focuses on the control of the acute infection, relief of acute pain, and prevention of chronic pain. First line treatment is pharmacological using antiviral and analgesic drugs, and epidural injections have been used for the prevention of post-herpetic neuralgia. ObjectiveThe objective of this article is to present a review of the literature on the basis of a case report of a patient diagnosed with herpes zoster who was treated with cervical epidural infusions for 16 days. Materials and methodsSearch conducted in PUBMED, including meta-analyses, systematic reviews, clinical trials, narrative reviews and case series published between 1995 and 2012, in order to perform a non-systematic narrative review in reference to a case report. ResultsOverall, 31 articles were selected for an update of the topic proposed, and a case report was described. ConclusionsThe use of epidural infusions in patients with herpes zoster is a treatment option for acute pain; it favors passive motion of the affected limb preventing atrophy, helps prevent post-herpetic neuralgia, is available in our setting, and has a low incidence of complications.

Herpes Zoster: Diagnostic, Therapeutic, and Preventive Approaches

Herpes zoster (Hz), which generally presents as a localized, painful cutaneous eruption, is a common clinical problem, particularly among adults ≥ 50 years of age and immunocompromised patients. The diagnosis of Hz is mainly made clinically, except in patients with atypical manifestations or certain complications, such as central nervous system involvement, in which laboratory virologic testing is required. In addition to having a higher mortality rate, immunocompromised individuals have atypical and severe clinical findings and are at greater risk for complications and recurrence of Hz. Treatment of Hz includes the use of antiviral agents, analgesics for control of acute zoster pain, good skin care for healing, and prevention of secondary bacterial infection. Antiviral agents, preferably valacyclovir or famciclovir, should be started within 72 hours of onset to reduce the severity of the infection, the duration of the eruptive phase, and the intensity of acute pain. Herpes zoster has been associated with several complications, of which post-herpetic neuralgia (PHN) is the most common and debilitating. Varicella-zoster virus vaccine and early treatment with either famciclovir or valacyclovir are the only measures proven to prevent PHN. The options for treating PHN include topical agents, such as lidocaine patches, and systemic agents, such as the anticonvulsants gabapentin and pre-gabalin. Measures for preventing Hz include infection control through routine hand hygiene and appropriate use of isolation precautions and personal protective equipment; immunoglobulins, such as the varicella-zoster virus immunoglobulin and vaccine; and antiviral agents. The zoster vaccine has been shown to be effective in reducing the incidence of Hz and PHN. The vaccine is recommended for all individuals aged ≥ 60 years who have no contraindications, including individuals who report a previous episode of Hz.

Options in Topical Therapies in the Management of Patients With Acute Pain

The traditional cornerstones of analgesic therapy for patients with acute pain have been oral therapies; however, all oral agents exhibit a variety of potentially dose-limiting or intolerable adverse effects in patients. Elderly patients and those with concomitant conditions already being managed with multiple systemic drugs may be particularly susceptible to systemic toxicities with oral analgesic therapies. Topical agents offer an alternative to oral modalities and can effectively treat patients with acute pain while offering lower systemic absorption and conferring little risk of systemic toxicity. The objective of this article is to review the therapeutic usefulness of available topical therapies in their most thoroughly investigated applications, the treatment of patients with acute musculoskeletal and herpetic pain. For example, although heating pads/wraps and cold packs are widely used to alleviate pain associated with sprains, strains, and contusions, evidence of the effectiveness of these methods is lacking. However, there are sufficient data supporting the use of various topical formulations of nonsteroidal anti-inflammatory drugs (NSAIDs) for these indications (ketoprofen gel or patch, ibuprofen gel or cream, and diclofenac gel or patch), and demonstrating markedly less patient risk of systemic toxicity than is associated with oral NSAID therapy. A ketoprofen patch was shown to be effective and well tolerated in the treatment of patients with tendinopathies. In the treatment of acute neck or low back pain, cold and heat therapies have demonstrated limited effectiveness for patients, and the efficacy of topical NSAIDs has not been established. Use of topical NSAID therapy has been useful in reducing acute-phase herpes zoster pain, and the lidocaine 5% patch has been shown to reduce acute herpetic pain intensity once lesions have healed (the patch cannot be applied to open skin lesions). Topical analgesics represent an alternative treatment modality for patients experiencing acute pain who cannot or choose not to take oral therapies.