POST-HERPETIC
NEURALGIA
AND ITS
MANAGEMENT
DR. AYESHA ASLAM
Post herpetic Neuralgia is defined as pain
along cutaneous nerves persisting for
more than 30 days after the onset of
Herpes Zoster rash.
INCIDENCE
incidence of post herpetic neuralgia
increases with age
uncommon in patients younger than 60
years
10
9
8
8.8
7
6
5
4
3
2
2.0
1
0
01 MONTH
03 MONTHS
PATIENTS < 60 YRS
01 YEAR
45
40
40.8
35
30
25
INCIDENCE
20
15
13.0
10
7.8
5
0
01 MONTH
03 MONTHS
01 YEAR
PATIENTS > 60 YRS
PATHOPHYSIOLOGY OF PHN
Varicella
neurochemical
FREQUENCY
In US each year approximately 1,000,000
individuals develop herpes zoster.
Of those individuals approximately 20%,
or 200,000 individuals, develop
postherpetic neuralgia.
PRE-DISPOSING
FACTORS
Susceptibility to HZ - > in caucasians
Old & Debilitated
Immuno-compromised patients
Acute neuritis in the early phase of
disease
CLINICAL
PRESENTATION
SYMPTOMS:
Pain
- ranges from mild discomfort to severe
burning, aching or gnawing
- constant
Allodynia
Headaches
Fatigue
Sleep disturbances
PAIN INTENSITY IN PHN
SIGNS:
Cutaneous scarring of HZ lesions in the
affected areas
Altered sensations over the affected
dermatome
- Lowered threshold for cold, warmth
& vibration
- Poor two-point discrimination
Muscle weakness, tremor or paralysis -if
the nerves involved also control muscle
movement
SCARRING AND PIGMENTARY CHANGES IN
THE AFFECTED DERMATOME
DIAGNOSIS
History
Examination - dermatomal pattern of
distribution and the appearance of the herpes
zoster rash
In cases where the diagnosis
is in doubt:
PCR Techniques - detect the varicella DNA in
fluid taken from the vesicles
Direct Immunofluorescent Antigen
Staining Test
VZ specific IgM
Virus cultures
PREVENTION
No treatment has been shown to prevent
postherpetic neuralgia completely.
However, some treatments may shorten
the duration or lessen the severity of
symptoms.
Prevention could be:
Primary
Secondary
PRIMARY PREVENTION
The only really effective way of preventing
post herpetic neuralgia from developing is
to protect yourself from shingles and/or
chicken pox with the
chickenpox (varicella) vaccine
the shingles (varicella-zoster)
vaccine
CHICKENPOX VACCINE
Varivax vaccine
routinely given to children aged 12 -18
months to prevent chickenpox
also recommended for adults and older
children who have never had chickenpox
does not provide 100% immunity but
reduces the risk of complications and
severity of the disease.
VACCINE FOR CHICKENPOX
SHINGLES VACCINE
Zostavax vaccine
helps protect adults over 60 who have had
chickenpox.
Recommended
that people over 60 have this vaccine
, regardless of whether or not they h
ave had shingles before
.
The vaccine is preventative, and is not
used to treat people who are infected.
VACCINE FOR SHINGLES
SECONDARY
PREVENTION
Aggressively treating shingles with
antiviral agents such as Acyclovir within
02 days of the rash can reduce both the
risk of developing subsequent neuralgia or
the length and severity if it does.
TREATMENT OF PHN
DIRECT PAIN INHIBITION
ANALGESICS
o Topical
o Systemic
PAIN MODIFICATION THERAPY
ANTI-DEPRESSANTS
ANTI-CONVULSANTS
STEROIDS
OTHERS
TENS
PERIPHERAL NERVE STIMULATION
SPINAL CORD STIMULATION
SURGICAL INTERVENTION
1. ANALGESICS
TOPICAL AGENTS
Lidocaine Skin Patches
small, bandage-like patches that contain
lidocaine
must be applied directly to painful skin to
deliver relief for 04-12 hours.
avoid contact with mucus membranes
e.g. eyes, nose and mouth.
TOPICAL CAPSAICIN
an extract of hot chilli peppers
depletes substance P from nerve
terminals & desensitizes them
0.025 % cream (Zostrix) applied four times
daily
EMLA
A eutectic mixture of lidocaine and
prilocaine
Reported to be beneficial in pain relief
Aspirin
mixed into an appropriate solvent such as
diethyl ether may reduce pain
SYSTEMIC AGENTS
OPIOIDS
- Oxycodone (Oxycontin) 10 mg twice
daily
- a small risk of dependency exists
PAIN MODIFICATION
THERAPY
1. TRICYCLIC
ANTI- DEPRESSANTS
Affect key brain chemicals, such as
serotonin and norepinephrine
Influence how the body interprets pain
Dosages tend to be lower
Examples include
Amitriptyline 10-75mg /d
Desipramine (Norpramin) 25mg/d
Nortriptyline (Pamelor) 10-25mg/d
Duloxetine (Cymbalta)
AMITRIPTYLINE
Single most effective drug
Anticholinergic and cardiovascular sideeffects must be considered
Given at bedtime to improve tolerance
and prevent daytime somnolence
2. ANTI-CONVULSANTS
effective in calming down nerve impulses
stabilize abnormal electrical activity in the
nervous system caused by injured nerves
Effective in patients who experience
stabbing pain in addition to the burning
sensation
Examples include
Gabapentin (Neurontin) 100-300mg/d
Pregabalin (Lyrica) 50-75mg/d
Lamotrigine (Lamictal)
Carbamazepine (Tegratol)
Phenytoin (Dilantin)
3. STEROIDS
METHYLPREDNISOLONE is injected into
the area around the spinal cord i.e
intrathecally
Effective for patients with chronic pain
Administered only after the shingles
pustular skin rash has completely
disappeared
Patients unresponsive to oral/topical
therapy should be considered
TRANSCUTANEOUS ELECTRIC
NERVE STIMULATION
Electrodes are placed over the areas
where pain occurs
Small electrical impulses are emitted and
provide pain relief
The patient turns the TENS device on and
off as required
TENS stimulates ENDORPHIN releasethe body's natural painkillers
PERIPHERAL NERVE
STIMULATION
The devices are surgically implanted
under the skin, along the course of
peripheral nerves.
As soon as the electrodes are in place,
they are switched on to administer a weak
electrical current to the nerve.
The patient will have a tingling sensation
in the area.
SPINAL CORD
STIMULATION
The spinal cord stimulator is inserted
through the skin into the epidural space
over the spinal cord
Works in the same way as peripheral
nerve stimulator
SURGICAL TREATMENT
For patients who do not respond to
medical therapy
Outcome of surgical procedures in case of
PHN is far from certain in regard to pain
management
Blockade of affected nerves
Neurectomy
Surgery at the level of dorsal root
ganglion
PROGNOSIS
The natural history of PHN involves slow
resolution of the pain syndrome
In those patients who develop PHN, most
will respond to agents such as the
Tricyclic Antidepressants
A subgroup of patients may develop
severe, long-lasting pain that does not
respond to medical therapy
