Shingles / PHN (Postherpetic Neuralgia)

Shingles, or acute herpes zoster infection, is a common complication of reactivated varicella zoster virus (chicken pox). In turn, this may foster development of the chronic pain syndrome, postherpetic neuralgia (PHN). Shingles begins as pain in a dermatomal distribution with a rash consisting of papules and vesicles, along with malaise and fever. PHN has been defined as pain persisting or recurring at the site of shingles at least one month after onset of the acute rash. The pain of PHN may last for a few months or a lifetime.

The incidence of shingles increases sharply in patients over 50 years of age. Shingles also occurs more frequently in immunocompromised patients, and they are also more likely to suffer from PHN. A variety of agents have been reported for treating PHN, including opioids, topical lidocaine and capsaicin, antidepressants, and antiepileptics. Therefore, clinicians and patients have an array of options for treating PHN, which nonetheless can be difficult to manage and patients may suffer debilitating symptoms and inadequate pain relief.

Researchers/reviewers: Winnie Dawson, MA, RN, BSN; Stewart B. Leavitt, MA, PhD.

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Herpes Zoster

From: Medscape Reference; updated May 2011. Access checked 5/26/11.

See HTML article at: http://emedicine.medscape.com/article/1132465-overview

Beginning with a description of the pathophysiology of herpes zoster (shinges), this resource includes information on the presentation, differential diagnosis, examination and testing, treatment, and follow-up of the condition. The treatment section includes guideline summaries from several professional practice organizations, including a varicella prevention guideline from the American Academy of Pediatrics. Vaccine information and patient education suggestions are provided, as well as several useful links for antiviral dosing information and other related topics.

 

Postherpetic Neuralgia: An Overview of the Pathophysiology, Presentation, and Management

By: Gharibo C, Kim C. Pain Medicine News. 2011(Apr); 8 pages. Access checked 5/26/11.

PDF available for download: http://www.painmedicinenews.com/download/PostNeuralgiaPMN0411_WM.pdf

This article reviews the research explaining current understanding of the pathophysiology of postherpetic neuralgia (PHN). The discussion includes graphic illustrations showing PHN pain pathways as well as the process of peripheral and central sensitization following nerve injury. The authors recommend that the selection of a treatment strategy for the disorder — characterized by persistent neuropathic pain about 3 months following appearance of the rash of a herpes zoster infection — be initiated after considering 6 factors that are outlined in the article.

 

Alarming New Evidence About Painful Shingles-PHN

From: Pain-Topics UPDATES, 2011(Feb 11). Access checked 5/31/11.

See HTML article at: http://updates.pain-topics.org/2011/02/alarming-new-evidence-about-painful.html

Conventional wisdom about shingles, or herpes zoster, has been that it is a one-time occurrence and, thereafter, patients are protected from re-emergence of the varicella zoster virus that causes shingles. However, according to new evidence, recurrences of shingles may be more common than previously suspected. At the same time, other research reports that, while herpes zoster vaccine can be effective in reducing first time occurrences of shingles, relatively few persons at risk bother to get vaccinated.

 

Herpes Zoster (Shingles) and Postherpetic Neuralgia. Concise Review for Clinicians

By: Sampathkumar P, Drage LA, Martin DP. Mayo Clinic Proceedings. 2009(Mar);84(3):274-280. Access checked 5/26/11.

PDF available for download: http://www.mayoclinicproceedings.com/content/84/3/274.full.pdf+html

This article reviews the clinical manifestations, diagnosis, and treatment of herpes zoster (shingles), as well as the painful complication of postherpetic neuralgia (PHN). The authors emphasize the fact that early diagnosis and treatment of herpes zoster can reduce the incidence of PHN. Antiviral, corticosteroid, and analgesic agents are recommended for the treatment of acute herpes zoster. The challenges of treating PHN are reviewed and a discussion of drug therapy includes topical agents, antidepressants, anticonvulsants, and opioids. The benefits and cost considerations of the herpes zoster vaccine are presented.

 

Shingles: Hope Through Research

From: National Institutes of Health, National Institute of Neurological Disorders and Stroke; updated as of February 2011. Access checked 5/26/11.

See HTML article at: http://www.ninds.nih.gov/disorders/shingles/detail_shingles.htm

The National Institutes of Health provides a basic overview of shingles and postherpetic neuralgia (PHN), one complication of shingles. Answers to questions on contagion and the potential for fetal risk of infection during pregnancy are provided. Information on the shingles vaccine includes a brief description of benefits from the "Shingles Prevention Study." The website offers a link to a Spanish language version of this information.

 

Recommendations for the Management of Herpes Zoster

By: Dworkin RH, Johnson RW, Breuer J, et al. Clinical Infectious Diseases. 2007(Jan 1);44(Suppl 1):S1-26. Access checked 5/26/11 [Guideline provided by the Agency for Healthcare Research and Quality (AHRQ).]

See HTML document at: http://guideline.gov/content.aspx?id=10222

This document provides evidence-based recommendations for the treatment of patients with herpes zoster (shingles). In addition to efficacy, considerations in the choice of treatment include safety, tolerability, and effect on quality of life. Treatment recommendations include dosing instructions and provide additional guidance for patients who are immunocompromised, have ophthalmic complications, or are pregnant, frail, or elderly. Drug contraindications and adverse effects are reviewed. Like all AHRQ guideline postings, any subsequent FDA Warnings that relate to drugs discussed are shown at the top of the document.

 

Practice Parameter: Treatment of postherpetic neuralgia — An evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology

By: Dubinsky RM, Kabbani H, El-Chami Z, et al. Neurology. 2004(Sep 28);63(6):959-965. Access checked 5/26/11. [The American Academy of Neurology reports that this practice recommendation is current as of May 2011.]

PDF available for download: http://www.neurology.org/content/63/6/959.full.pdf

Postherpetic neuralgia (PHN) can be debilitating for the patient and challenging to manage. This systematic review analyzed the evidence and identified treatments that provide the most effective reduction in pain and improved quality of life. Recommendations include graded levels of evidence that show tricyclic antidepressants, gabapentin, pregabalin, opioids, and the lidocaine patch as the most effective products for pain reduction in PHN.

 

Shingles Vaccination: What You Need to Know

From: Centers for Disease Control and Prevention (CDC); updated January 2011. Access checked 5/26/11.

See HTML article at: http://www.cdc.gov/vaccines/vpd-vac/shingles/vacc-need-know.htm

The CDC recommends the Zostavax® shingles vaccine for adults aged 60 and older. This website provides a basic overview of the vaccine, including information on possible reactions to the vaccine and a list of people who should not receive the shingles vaccine.

Note: In March 2011, the FDA lowered the originally approved age of 60 years and older for Zostavax administration to 50 years and older. The decision was based on additional post-approval studies that showed a 70% reduction in the risk of developing shingles for vaccinated persons aged 50-59 when compared with those receiving placebo.

 

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