post Herpetic neuralgia
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Introduction
Dermatomal pain persisting at least 90 days after the appearance of the acute herpes zoster rash[10]
Etiology
- Herpes zoster
- risk factors
* 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
- gabapentin (Neurontin)[3] {treatment of choice[4][6]}
- pregabalin also effective
- tricyclic antidepressants
- transcutaneous electrical nerve stimulation (TENS)
- topical capsaicin, topical lidocaine
- treatment of choice in the elderly[16]
- famciclovir (Famvir) 500 mg TID for 7 days
- intrathecal or epidural methylprednisolone plus lidocaine or bupivacaine weekly[2]; 7-21 days[5]
- a single epidural injection methylprednisolone plus bupivicaine not effective[5]
- investigational angiotensin 2 receptor-2 antagonist EMA401 may be useful for treating postherpetic neuralgia[8]
- opiates, short term or as a last resort in refractory cases[9]
- consultation with pain-management specialist may be prudent
- prognosis:
- < 50% of patients report > 50% reduction in pain[9]
- adverse effect of treatment are common, especially in elderly[9]
- 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]
More general terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 866
- ↑ 2.0 2.1 Journal Watch 21(1):10, 2001 Kotani et al N Engl J Med 343:1514, 2000
- ↑ 3.0 3.1 Prescriber's Letter 9(7):39 2002
- ↑ 4.0 4.1 4.2 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 - ↑ 5.0 5.1 5.2 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: https://www.ncbi.nlm.nih.gov/pubmed/16427490
Baron R, Wasner G. Prevention and treatment of postherpetic neuralgia. Lancet. 2006 Jan 21;367(9506):186-8. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16427472 - ↑ 6.0 6.1 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: https://www.ncbi.nlm.nih.gov/pubmed/21482862
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/20510264
- ↑ 8.0 8.1 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24507377 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2962337-5/abstract
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Johnson RW, Rice AS Postherpetic Neuralgia N Engl J Med 2014; 371:1526-1533 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25317872 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcp1403062
- ↑ 10.0 10.1 Fazio S Postherpetic Neuralgia Now@NEJM. Oct 17, 2014 http://blogs.nejm.org/now/index.php/postherpetic-neuralgia/2014/10/17/
- ↑ 11.0 11.1 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: https://www.ncbi.nlm.nih.gov/pubmed/19370655 - ↑ 12.0 12.1 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: https://www.ncbi.nlm.nih.gov/pubmed/18254083 - ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/15452284
- ↑ Argoff CE. Review of current guidelines on the care of postherpetic neuralgia. Postgrad Med. 2011 Sep;123(5):134-42. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21904096
- ↑ 15.0 15.1 15.2 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27287218 <Internet> http://www.neurology.org/content/87/1/94
- ↑ 16.0 16.1 Medical Knowledge Self Assessment Program (MKSAP) 17, 18 American College of Physicians, Philadelphia 2015, 2018.
- ↑ 17.0 17.1 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: https://www.ncbi.nlm.nih.gov/pubmed/38050854 Review.