post herpetic neuralgia and herpes zoster

7/25/2019 Post Herpetic Neuralgia and Herpes Zoster

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Acute Herpes Zoster&

Post herpetic

Neuralgia

Dr Mehran Rezvani pain fellowshipanesthesiologist & acupuncturist



Herpes zoster

Herpes zoster is an infectious diseasethat is caused by the varicellazostervirus

!t is postulated that during the courseof pri"ary infection with #Z#$ thevirus "igrates to the dorsal root orcranial ganglia




Herpes zoster

!n so"e individuals the virus "ayreactivate and travel along peripheralor cranial sensory pathways to the

nerve endings$ producing the pain ands%in lesions characteristic of shingles

he reason for reactivation 'decrease in cell"ediated i""unity




Ris% factors

(u)ering fro" "alignancies *particularly

ly"pho"a+

Receiving i""unosuppressive therapy

*che"otherapy$ steroids$ radiation+

,enerally debilitated by chronicdiseases

Patients older than 60 years




(!,N( AND (-MP.M(

Herpetic pain/ 01 day before of skin lesions

May be acco"panied by 2uli%e sy"pto"s

Progresses fro" a dull$ aching sensation tounilateral$(eg"ental$ bandli%e dysesthesias andhyperpathia

3urning pain $ hyperesthesia$ allodynia Zoster sine herpete




(!,N( AND (-MP.M(

4ro" a "ild selfli"ited proble" to adebilitating$ constantly burning painthat is e5acerbated by light touch$

"ove"ent$ an5iety$and6orte"perature change

7an lead to suicide




(!,N( AND (-MP.M(

horacic der"ato"es 089

7ervical region 8:9

rige"inal nerve ;19lu"bosacral region !! 9

Ra"say Hunt syndro"e




(!,N( AND (-MP.M(

Skin lesions

7rops of "acular lesions

Papules

#esicles7rusting

7rusts fall away *(cabs+

Pin% scars

Hypopig"ented and atrophic scars




Diferential Diagnosis< Appendicitis< !ntervertebral discdisease< Myocardial infarction< Pleurisy

< Renal stone< rige"inal neuralgia< 7holecystitis< ,lauco"a< 3ell=s palsy< 3rachioradial pruritus< 3ullous i"petigo< 3ullous pe"phigoid< 7andidiasis

< 7aterpillar der"atitis

< 7ontact der"atitis< >rysipelas< 4olliculitis< !ncontinentia pig"enti< ?elly@sh sting

< ichen striatus< Pe"phigus< Photoallergic reaction< Phytophotoder"atitis< Rhus der"atitis< Brticaria< Zosterifor" herpes< Zosterifor" "etastasis< 7ellulitis




7.MP!7A!.N(




TREATMENT

Relief of acute pain and sy"pto"s

Prevention of co"plications$ includingpostherpetic neuralgia

>arlier treat"entless li%ely postherpetic

neuralgia




TREATMENT

7areful initial evaluation$ including athorough history and physicale5a"ination$ is indicated to rule out

occult "alignancy or syste"icdisease




TREATMENT

(y"pathetic neural bloc%ade appears

to be the treat"ent of choice torelieve the sy"pto"s of acuteherpes zoster as well as to preventthe occurrence of postherpeticneuralgia

Noordenbos C@ber dissociationC




TREATMENT

Herpes zoster in trige"inal nerve & geniculate$cervical$ and high thoracic regions/

stellate ganglionbloc%ade with

A daily basisHerpes zoster thoracic$ lu"bar$ and sacral

regions/

epidural neural bloc%ade with

Adaily basis




TREATMENT

• !f the pain is not as severe$ N(A!Ds oraceta"inophen "ay be all that isneeded

• !n acute eruption oral narcotics "aybe

ad"inistered in the short ter"$especially with *N(A!Ds+




TREATMENT

Narcotic analgesics "ay be useful inrelieving the aching pain

Antidepressants will help / Alleviate the signi@cant sleep disturbance

A"eliorate the neurotic co"ponent of the pain

May e5ert a "oodelevating

May cause urinary retention and constipation




TREATMENT

Anticonvulsants

May be of value as an adunct to sy"pathetic

neural bloc%ade

hey "ay be particularly useful in persistentparesthetic or dysesthetic pain




TREATMENT

An5iety "ay be treated

Hydro5yzine3ehavioral interventions*eEgE$ "onitored rela5ation training and hypnosis+




TREATMENT

Antiviral agents/

Acyclovir $ valacyclovir$ fa"cyclovir and perhaps interferon have beenshown to shorten the course of acuteherpes zoster




TREATMENT

7orticosteroids

• !n syste"ic ' *the ris% of disse"ination'+

• ocal in@ltration of a)ected s%in areas with

corticosteroid with or without localanesthetic"ay be of value as an adunct to

sy"pathetic neural bloc%ade




TREATMENT

• ocal application of ice pac%s

• Application of heat

•

ranscutaneous electrical nervesti"ulation

• #ibration

•

(pinal cord sti"ulation




TREATMENT

• opical applicationAlu"inu" sulfat

Zinc o5ide oint"ent

opical lidocaine patches for PHN

opical capsaicin for PHN




Postherpetic

Neuralgia




Pain persisting after the rash hashealed *usually ; "onth *or8$ F$ or

even G"onths after the disease onset+ is

ter"ed PHN

Zosterassociated pain/

all pain beginning before$ at onset$ and afterthe rash




Negative and positive sy"pto"s

Allodynia is a characteristic feature ofPHN that occurs in the a)ected s%in

der"ato"esDysesthesias in the a)ected der"ato"e

spontaneous pain

Areas of sensory loss that lac% responsesto ther"al$ tactile$ pinpric%$ or vibratorysti"uli




PHN




Di)erential Diagnosis

horacic nerve roots include

horacic radiculopathy

Peripheral neuropathy !ntrathoracic and intraabdo"inal

pathology

.phtal"ic trige"inal nerve Diseases of the eye$ ear$ nose$ and

throat !ntracranial pathology




TREATMENT

• he anticonvulsant gabapentinrepresents a @rstline

• 7arba"azepine

• Phenytoin

• Antidepressants "ay also be useful




TREATMENT

(y"pathetic neural bloc%ade with localanesthetics and steroids via eitherepidural nerve bloc% or bloc%ade of

the sy"pathetic nerves "ay be ne5tstep '

• (o"e te5ts/ peripheral nerve$

epidural$ or sy"pathetic anestheticbloc%s do not appear to be useful




TREATMENT

Neurodestructive procedures have avery low success rate

.pioid analgesics have a li"ited role

Application of ice pac%s

Application of heat

ranscutaneous electrical nervesti"ulation

#ibration




4DA APPR.#>D

gabapentin

Pregabalin

opical lidocaine patch097apsaicin crea"




TREATMENT

opical local anesthetics$ such as>MA crea"

(ubcutaneous lidocaine in@ltration

!ntrathecal "ethylprednisolone

!"planted spinal catheters andpu"ps

Dorsal root entry zone lesion

3ehavioral therapy




TREATMENT

!n one controlled trial *otani et alE8:::+$

repeated intrathecal ad"inistrationof "ethylprednisolone acetateresulted in sustained pain relief inI:9 of PHN

he treat"ent was well tolerated




TREATMENT

!f the pain is severe$ and all other"ethods fail$ i""ediate pain relief"ay be obtained in hospitalized

patients with a short course of highdose chlorprothi5ene *0:"g every Ghours for 0 days+




Neurolytic bloc%s "ay be consideredin patients with PHN when otherbloc%s have not given the patient

signi@cantrelief (igni@cant pain relief has been

obtained in patientswith PHN using

acupuncture


S d N



Surgery and Neurosurgery

the last resort for the treat"ent ofsevere intractable postherpeticneuralgia/

7ordoto"y

Dorsal colu"n sti"ulators

Deep brain sti"ulators


post herpetic neuralgia and herpes zoster

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