Herpes zoster guideline of the German Dermatology Society (DDG)

Epidemiology and cost of herpes zoster and postherpetic neuralgia in Germany

After acquiring a varicella virus infection, the virus can reactivate and cause herpes zoster (HZ)--a painful skin rash. A complication of HZ is long-term persistence of pain after the rash has resolved (so-called postherpetic neuralgia, PHN). We aimed to describe the epidemiology of HZ/PHN and to estimate HZ/PHN-related costs in the German statutory health insurance (SHI) system (~85% of the total population). Treatment data of one large SHI was utilized, containing data on approximately 240,000 insured and their utilisation of services in 2004-2009. Identification of HZ- and PHN-cases was performed based on 'International Statistical Classification of Diseases' and specific medications using a control-group design. Incidences per 1,000 person-years (PY) and cost-of-illness for 1 year following HZ-onset considering the payer and societal perspective were calculated. All amounts were inflated to 2010 Euros. Population-figures were standardised and extrapolated to the total SHI-population in Germany in 2010. A mean annual incidence of 5.79 HZ-cases per 1,000 PY was observed, translating into an estimated 403,625 HZ-cases per year in the total SHI-population. Approximately 5% of HZ-cases developed PHN. One HZ-case caused on average euro 210 and euro 376 of costs from the payer and societal perspective, respectively. The development of PHN generated additional costs of euro 1,123 (euro 1,645 societal perspective). Total annual HZ/PHN-related costs were estimated at euro 182 million (euro 105 million) to society (payer). HZ and PHN place a considerable burden on the German SHI-system. Since HZ-vaccines will soon be available, a health-economic evaluation of these vaccines should be conducted.

Varicella zoster: an update on current treatment options and future perspectives

INTRODUCTION

Varicella zoster virus is a highly contagious virus that causes a primary infection known as varicella (chickenpox) that may reactivate years later to cause herpes zoster (HZ or shingles). After shingles heal, patients may develop post-herpetic neuralgia (PHN), neuropathic pain syndrome that can cause significant suffering for years and is often refractory to treatment.

AREAS COVERED

The wide range of treatment and management options for varicella, HZ and PHN are reviewed and discussed. PubMed was the database used for the literature search.

EXPERT OPINION

Antiviral therapy effectively treats acute varicella and HZ. However, PHN is still difficult to manage, especially with the numerous treatment measures that do not work consistently in all patients. The best approach is to prevent the complication from occurring in the first place by preventing HZ with the HZ vaccine, which have decreased the burden of illness caused by VZ and the incidence of HZ. Unlike the varicella vaccine, the uptake for the HZ vaccine is very low and thereby more patients over the age of 50 years should be encouraged to receive the vaccine to reduce the risk of developing HZ. Initiating treatment with gabapentin and antiviral concomitantly as soon as the rash develops may reduce the severity of complications but there is a lack of data showing these medications preventing the development of PHN.

Health economic evaluation of vaccination strategies for the prevention of herpes zoster and postherpetic neuralgia in Germany

BACKGROUND

Herpes zoster (HZ) is a self-limiting painful skin rash affecting mostly individuals from 50 years of age. The main complication is postherpetic neuralgia (PHN), a long-lasting pain after rash has resolved. A HZ-vaccine has recently been licensed in Europe for individuals older than 50 years. To support an informed decision-making for a potential vaccination recommendation, we conducted a health economic evaluation to identify the most cost-effective vaccination strategy.

METHODS

We developed a static Markov-cohort model, which compared a vaccine-scenario with no vaccination. The cohort entering the model was 50 years of age, vaccinated at age 60, and stayed over life-time in the model. Transition probabilities were based on HZ/PHN-epidemiology and demographic data from Germany, as well as vaccine efficacy (VE) data from clinical trials. Costs for vaccination and HZ/PHN-treatment (in Euros; 2010), as well as outcomes were discounted equally with 3% p.a. We accounted results from both, payer and societal perspective. We calculated benefit-cost-ratio (BCR), number-needed-to-vaccinate (NNV), and incremental cost-effectiveness ratios (ICERs) for costs per HZ-case avoided, per PHN-case avoided, and per quality-adjusted life-year (QALY) gained. Different target age-groups were compared to identify the most cost-effective vaccination strategy. Base-case-analysis as well as structural, descriptive-, and probabilistic-sensitivity-analyses (DSA, PSA) were performed.

RESULTS

When vaccinating 20% of a cohort of 1 million 50 year old individuals at the age of 60 years, approximately 20,000 HZ-cases will be avoided over life-time. The NNV to avoid one HZ (PHN)-case was 10 (144). However, with a BCR of 0.34 this vaccination-strategy did not save costs. The base-case-analysis yielded an ICER of 1,419 (20,809) Euros per avoided HZ (PHN)-case and 28,146 Euros per QALY gained. Vaccination at the age of 60 was identified in most (sensitivity) analyses to be the most cost-effective vaccination strategy. In DSA, vaccine price and VE were shown to be the most critical input-data.

CONCLUSIONS

According to our evaluation, HZ-vaccination is expected to avoid HZ/PHN-cases and gain QALYs to higher costs. However, the vaccine price had the highest impact on the ICERs. Among different scenarios, targeting individuals aged 60 years seems to represent the most cost-effective vaccination-strategy.

Similar herpes zoster incidence across Europe: results from a systematic literature review

Background

Herpes zoster (HZ) is caused by reactivation of the varicella-zoster virus (VZV) and mainly affects individuals aged ≥50 years. The forthcoming European launch of a vaccine against HZ (Zostavax®) prompts the need for a better understanding of the epidemiology of HZ in Europe. Therefore the aim of this systematic review was to summarize the available data on HZ incidence in Europe and to describe age-specific incidence.

Methods

The Medline database of the National Library of Medicine was used to conduct a comprehensive literature search of population-based studies of HZ incidence published between 1960 and 2010 carried out in the 27 member countries of the European Union, Iceland, Norway and Switzerland. The identified articles were reviewed and scored according to a reading grid including various quality criteria, and HZ incidence data were extracted and presented by country.

Results

The search identified 21 studies, and revealed a similar annual HZ incidence throughout Europe, varying by country from 2.0 to 4.6/1 000 person-years with no clearly observed geographic trend. Despite the fact that age groups differed from one study to another, age-specific HZ incidence rates seemed to hold steady during the review period, at around 1/1 000 children <10 years, around 2/1 000 adults aged <40 years, and around 1–4/1 000 adults aged 40–50 years. They then increased rapidly after age 50 years to around 7–8/1 000, up to 10/1 000 after 80 years of age. Our review confirms that in Europe HZ incidence increases with age, and quite drastically after 50 years of age. In all of the 21 studies included in the present review, incidence rates were higher among women than men, and this difference increased with age. This review also highlights the need to identify standardized surveillance methods to improve the comparability of data within European Union Member States and to monitor the impact of VZV immunization on the epidemiology of HZ.

Conclusions

Available data in Europe have shortcomings which make an accurate assessment of HZ incidence and change over time impossible. However, data are indicative that HZ incidence is comparable, and increases with age in the same proportion across Europe.

A population-based case-control analysis of the association between herpes zoster and erectile dysfunction

PURPOSE

To date, the occurrence of erectile dysfunction (ED) associating with herpes zoster (HZ) is only based on limited case reports. This case-control study aimed at examining the association between HZ and ED using a population-based dataset in Taiwan.

METHODS

A total of 6429 adults newly diagnosed with ED were identified as cases, and 38,574 subjects without any medical history of ED were extracted as controls. Conditional logistic regression models were performed.

RESULTS

In total, 1.03% out of the sampled subjects had been diagnosed with HZ within one year prior to the index date; a higher proportion of prior HZ was found among cases than controls (2.04% vs. 0.86%, p < 0.001). After adjusting for demographic characteristics, hypertension, diabetes, coronary heart disease, hyperlipidemia, obesity, and alcohol abuse/alcohol dependence syndrome, conditional logistic regression suggested that cases were more likely to have previously been diagnosed with HZ than controls (OR = 2.24, 95% CI = 1.82-2.75). Furthermore, the odds of having been diagnosed with an HZ infection within one year prior to the index date were dramatically higher among patients with ED than controls among subjects aged 18-29 (OR = 6.07).

CONCLUSIONS

We conclude that ED was associated with having been previously diagnosed with HZ, particularly among younger males.

Herpes zoster ophthalmicus

OPINION STATEMENT

The management of herpes zoster (HZ) usually involves a multidisciplinary approach aiming to reduce complications and morbidity. Patients with herpes zoster ophthalmicus (HZO) are referred to ophthalmologists for prevention or treatment of its potential complications. Without prompt detection and treatment, HZO can lead to substantial visual disability. In our practice, we usually evaluate patients with HZO for corneal complications such as epithelial, stromal, and disciform keratitis; anterior uveitis; necrotizing retinitis; and cranial nerve palsies in relation to the eye. These are acute and usually sight-threatening. We recommend oral acyclovir in conjunction with topical 3% acyclovir ointment, lubricants, and steroids for conjunctival, corneal, and uveal inflammation associated with HZO. Persistent vasculitis and neuritis may result in chronic ocular complications, the most important of which are neurotrophic keratitis, mucus plaque keratitis, and lipid degeneration of corneal scars. Postherpetic complications, especially postherpetic neuralgia (PHN), are observed in well over half of patients with HZO. The severe, debilitating, chronic pain of PHN is treated locally with cold compresses and lidocaine cream (5%). These patients also receive systemic treatment with NSAIDs, and our medical colleagues cooperate in managing their depression and excruciating pain. Pain is the predominant symptom in all phases of HZ disease, being reported by up to 90% of patients. Ocular surgery for HZO-related complications is performed only after adequately stabilizing pre-existing ocular inflammation, raised intraocular pressure, dry eye, neurotrophic keratitis, and lagophthalmos. Cranial nerve palsies are common and most often involve the facial nerve, although palsy of the oculomotor, trochlear, and abducens nerves may occur in isolation or (rarely) simultaneously. In our setting, complete ophthalmoplegia is seen more often than isolated palsies, but recovery is usually complete. Vasculitis within the orbital apex (orbital apex syndrome) or brainstem dysfunction is postulated to be the cause of cranial nerve palsies. A vaccine of a lyophilized preparation of the oka strain of live, attenuated varicella-zoster virus is suggested for patients who are at risk of developing HZ and has been shown to boost immunity against HZ virus in older patients.

Resistance testing of clinical varicella-zoster virus strains

Acyclovir resistance of varicella-zoster virus (VZV) has been reported in rare cases of immunocompromised patients. In this study, the natural polymorphism of the thymidine kinase (TK) and DNA polymerase (pol) genes was examined in 51 clinical VZV isolates sensitive to acyclovir (ACV). In addition, 16 VZV strains with clinical resistance to ACV were analyzed. None of the ACV-sensitive strains of the clades 1, 3 and 5 showed gene polymorphism of the TK. By contrast, the DNA pol gene exhibited polymorphism-related substitutions as a function of the VZV clade. The novel substitutions M286I, E824Q, R984H and H1089Y were detected in strains of clades 3 and 5. In the TK gene of 7 VZV strains with clinical ACV resistance, the novel substitutions L73I, A163stop, W225R, T256M, N334stop and the deletion of nucleotides 19-223 were found to be associated most likely with resistance. In one strain showing the substitution W225R, ACV resistance could be confirmed by the viral phenotype. In the DNA pol gene, the novel amino acid substitutions T237K and A955T could be detected, but their significance remains unclear. In conclusion, the characterization of resistance using genetic analysis of the TK and DNA pol genes has to be considered the method of choice for the determination of VZV resistance to antiviral drugs. In a considerable number of patients with clinical ACV-resistant VZV infections, resistance cannot be verified by virological methods.

[Burden of herpes zoster and postherpetic neuralgia: Incidence, proportion, and associated costs in the French population aged 50 or over]

BACKGROUND

Despite the perspective of vaccination against herpes zoster, there are few recent data available on the incidence of this disease, the proportion of postherpetic neuralgia cases, and associated disease management costs. This study was performed to evaluate these parameters in a representative sample of French physicians.

METHODS

It was a retrospective, declarative study conducted from the medical files of patients who presented with herpes zoster and consulted in 2005, based on a random sample of GPs, dermatologists, neurologists, and physicians in pain clinics, weighted by demographic departmental distribution of patients aged 50 years and above. The analysis was performed on cases diagnosed by physicians themselves (incident cases).

RESULTS

The annual incidence of herpes zoster was estimated at 8.99/1000 [8.34-9.64], all types of physicians pooled and at 8.67/1000 for GPs. This represents about 182,500 cases of herpes zoster in France in 2005 in patients aged 50 years and above. Incidence was slightly higher amongst women (1.3 times) and increased with age. Amongst the 777 cases of incident herpes zoster, 343 were complicated by postherpetic neuralgia one month after diagnosis. The proportion of patients presenting postherpetic neuralgia at 3 and 6 months was 32.1% and 17.6%, respectively. The annual cost of management of herpes zoster and postherpetic neuralgia was estimated at 170 [109-249] million euros, of which 61.0 million euros were covered by the national health insurance.

CONCLUSION

In this study, the incidence of herpes zoster observed in France in subjects aged 50 years and above is close to that already estimated in France and Europe. The proportion of postherpetic neuralgia is high and this painful complication may persist for several months after diagnosis of herpes zoster. To our knowledge, EPIZOD is the first study conducted in France to assess the cost of herpes zoster and of postherpetic neuralgia, the most frequent complication of this viral disease.

Epidemiology and economic burden of herpes zoster and post-herpetic neuralgia in Italy: a retrospective, population-based study

BACKGROUND

Data on the epidemiology and cost of herpes zoster (HZ) and post-herpetic neuralgia (PHN) in Italy are limited. This retrospective, population-based study was designed to determine the incidence of HZ and the proportion developing PHN in Italy and the associated medical resource utilisation and costs. It focused primarily on immunocompetent patients aged > or = 50 years who would be eligible for preventive vaccination.

METHOD

Data were extracted from a primary-care database and national hospital-discharge records covering four major regions in Italy for 2003-2005. Cases of HZ and PHN (1 and 3 months' duration; PHN1 and PHN3) were identified by ICD9-CM codes and, additionally for PHN, prescription of neuropathic pain medication.

RESULTS

Over 3 years, 5675 incident cases of HZ were documented in adults, of which 3620 occurred in immunocompetent patients aged > or = 50 years (incidence of 6.31 per 1000 person-years [95% CI: 6.01-6.62]). Of the immunocompetent patients aged > or = 50 years with HZ, 9.4% (95% CI: 8.2-10.7) and 7.2% (95% CI: 6.2-8.2) developed PHN1 and PHN3, respectively. Increasing age, female sex, and being immunologically compromised conferred increased risk for both HZ and PHN. Overall, about 1.3% of HZ and almost 2% of PHN cases required inpatient care, with 16.9% of all HZ-related hospitalisations due specifically to PHN. In patients aged > or = 50 years, mean stay was 7.8 +/- 5.4 days for HZ and 10.2 +/- 8.6 days for PHN, and direct costs associated with inpatient care were more than 20 times outpatient costs per HZ case (mean +/- SD: euro2592 +/- euro1313 vs. euro122.68 +/- euro97.51) and over 5 times more per episode of PHN (mean +/- SD: euro2806 +/- euro2641 vs. euro446.10 +/- euro442.97). Total annual costs were euro41.2 million, of which euro28.2 million were direct costs and euro13.0 million indirect costs.

CONCLUSIONS

This study, the largest to date on the epidemiology and economic impact of HZ and PHN in Italy, confirms the considerable disease and economic burden posed by HZ. As HZ and PHN disproportionately affect the elderly, without intervention this problem is likely to grow as the proportion of elderly in the Italian population continues to increase.

Varicella-zoster virus reactivation from multiple ganglia: a case report

Introduction

Simultaneous involvements of multiple cranial nerve ganglia (geniculate ganglion and peripheral ganglia of cranial nerves VIII, IX and X) by varicella-zoster virus and its subsequent activation may result in the characteristic eruptions of herpes zoster cephalicus. Coexistence of facial palsy and involvement of upper cervical dermatomes by varicella-zoster virus is quite rare.

Case presentation

Here, we report a 71-year-old Iranian man with involvement of multiple sensory ganglia (geniculate ganglion and upper dorsal root ganglia) by varicella-zoster virus. He presented with right-sided facial weakness along with vesicular eruptions on the right side of his neck, and second and third cervical dermatomes.

Conclusion

The present case is an example of herpes zoster cephalicus with cervical nerve involvement. Although resembling Ramsay Hunt syndrome with presence of facial nerve paralysis and accompanying vesicles, involvement of cervical dermatomes is not a feature of the classic Ramsay Hunt syndrome.

Herpes zoster associated hospital admissions in Italy: review of the hospital discharge forms

In Italy a specific surveillance system for zoster does not exist, and thus updated and complete epidemiological data are lacking. The objective of this study was to retrospectively review the national hospital discharge forms database for the period 1999–2005 using the code ICD9-CM053. In the period 1999–2005, 35,328 hospital admissions have been registered with annual means of 4,503 hospitalizations and 543 day-hospital admissions. The great part of hospitalizations (61.9%) involved subjects older than 65 years; the mean duration of stay was 8 days. These data, even if restricted to hospitalizations registered at national level, confirm the epidemiological impact of shingles and of its complications.

Acupuncture in acute herpes zoster pain therapy (ACUZoster) - design and protocol of a randomised controlled trial

Background

Acute herpes zoster is a prevalent condition. One of its major symptoms is pain, which can highly influence patient's quality of life. Pain therapy is limited. Acupuncture is supposed to soften neuropathic pain conditions and might therefore act as a therapeutic alternative. Objective of the present study is to investigate whether a 4 week semi-standardised acupuncture is non-inferior to sham laser acupuncture and the anticonvulsive drug gabapentine in the treatment of pain associated with herpes zoster.

Methods/Design

Three-armed, randomised, placebo-controlled trial with a total follow-up time of 6 months. Up to estimated 336 patients (interim analyses) with acute herpes zoster pain (VAS > 30 mm) will be randomised to one of three groups (a) semi-standardised acupuncture (168 patients); (b) gabapentine with individualised dosage between 900–3600 mg/d (84 patients); (c) sham laser acupuncture. Intervention takes place over 4 weeks, all patients will receive analgesic therapy (non-opioid analgesics: metamizol or paracetamol and opioids: tramadol or morphine). Therapy phase includes 4 weeks in which group (a) and (c) consist of 12 sessions per patient, (b) visits depend on patients needs. Main outcome measure is to assess the alteration of pain intensity before and 1 week after treatment sessions (visual analogue scale VAS 0–100 mm). Secondary outcome measure are: alteration of pain intensity and frequency of pain attacks; alteration of different aspects of pain evaluated by standardised pain questionnaires (NPI, PDI, SES); effects on quality of life (SF 36); analgesic demand; alteration of sensoric perception by systematic quantitative sensory testing (QST); incidence of postherpetic neuralgia; side effects and cost effectiveness. Credibility of treatments will be assessed.

Discussion

This study is the first large-scale randomised placebo controlled trial to evaluate the efficacy of acupuncture compared to gabapentine and sham treatment and will provide valuable new information about the clinical and physiological effects of acupuncture and gabapentine in the treatment of acute herpes zoster pain. The study has been pragmatically designed to ensure that the study findings can be implemented into clinical practice if acupuncture can be shown to be an effective treatment strategy in acute herpes zoster pain.

Trial registration

NCT00885586

Topical glycopirrolate for the management of hyperhidrosis in herpetic neuralgia

Herpes zoster is a relapse of varicella. In certain cases, long-term pain and hyperhidrosis have been noted. Appearance of herpes zoster during pregnancy is infrequent. We described hyperhidrosis and pain treatment using glycopirrolate cream in a pregnant woman with herpetic neuralgia. A 32 year old woman, 21 weeks pregnant with second child, complained to her gynecologist of the appearance of a vesicular rash on the left half of the forehead that progressed toward her left eyelid, accompanied by lancinating pain, allodynia, hyperhidrosis and small edema, blepharitis and conjunctivitis. Following clinical and laboratory tests, she was diagnosed with herpes zoster ophtalmicus. Aciclovir therapy was administered 800 mg orally five times daily for seven days. Pain therapy was initiated with amitriptilline. We discontinued amitriptilline therapy after 10 days because of appearance of unwanted side effects. After skin changes ceased, we introduced Lidocaine patch into pain therapy which reduced the allodynia, but not the lancinating pain and hyperhidrosis. At that time we began using glycopirrolate cream which reduced pain intensity by 28.5% within 24 hours, and completely eliminated hyperhidrosis. After 48 hours of use, the pain completely disappeared. During the Glycopirrolate cream therapy, there were no side effects. This is a first report to document that a topical Glycopirrolate cream has a beneficial effect in a patient with hyperhidrosis and herpetic neuralgia.

Pain: basics and relevance in dermatology

Scientific progress in pathophysiology and differentiation of pain, functional diagnostic of pain and emerging treatments highlight this subject. Basics of development of pain, as well as differentiation of nociceptive and neuropathic pain are depicted; the latter is illustrated with the example of postherpetic neuralgia. Complex regional pain syndromes are described as a third pain complex. Principles of differentiated pain management are given. Substance groups from the WHO scheme including antipyretic analgesics, non-steroidal antiinflammatory drugs (NSAIDs) and opioids are discussed. Recommendations of the Drug Commission of the German Medical Association concerning NSAIDs and of the International Association for the Study of Pain (IASP) concerning new treatment options for cancer pain are cited. Overviews amongst others from the Cochrane library for local anesthetics, opioids and for the treatment of postherpetic neuralgia are included. Tables are provided to simplify use in daily practice. The goal of this overview is a conceptual development of pain diagnosis and therapy in dermatology.

Central nervous system involvement after herpes zoster ophthalmicus

PURPOSE

To report central nervous system involvement after varicella zoster virus infection.

METHODS

We evaluated the frequency and type of neurological complications in patients initially presenting with ophthalmic herpes zoster at an ophthalmological department in a Danish university hospital, over a 7-year period.

RESULTS

Of the 110 immunocompetent patients who presented with initial ophthalmic zoster, six (5.5%) suffered from neurological complications other than post-herpetic neuralgia. Four experienced isolated cranial motor nerve palsies, one patient had meningitis with a favourable outcome and one patient had severe encephalitis with a poor clinical outcome.

CONCLUSIONS

Central nervous system involvement after varicella zoster virus infection is an uncommon, but potentially life-threatening, complication. Early recognition of neurological complications prompts acute, appropriate antiviral treatment.

Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults

BACKGROUND

Herpes zoster oticus (HZO) is a viral infection of the ear and when associated with acute facial paralysis is known as Ramsay Hunt syndrome. Antiviral agents are the standard first-line treatment for herpes zoster infections at other body sites and are thought to reduce or minimise nerve damage, thereby improving outcomes. It has been suggested that these agents improve the chance of facial weakness improving or resolving completely in patients with Ramsay Hunt syndrome.

OBJECTIVES

To determine the effectiveness of antiviral agents in the treatment of adult patients with Ramsay Hunt syndrome (HZO with facial palsy).

SEARCH STRATEGY

We searched the Cochrane ENT Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medline (1950 - 2007), PubMed 2007 - 2008, EMBASE (1974 onwards) and other relevant databases. The date of the most recent search was June 2008.

SELECTION CRITERIA

Two authors scrutinized all possible citations to identify randomised controlled trials in which antiviral agents alone or in combination with other therapies (using different routes of administration and dosage schemes) were given as treatment for Ramsay Hunt syndrome. We contacted an author for further information.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and trial quality.

MAIN RESULTS

Only one randomised, controlled trial was identified and included. It was of low quality and included only 15 participants. In this 1992 trial, intravenous acyclovir and corticosteroids were compared with corticosteroids alone. Our analysis found no statistically significant difference between the two groups.

AUTHORS' CONCLUSIONS

We found no evidence that anti-viral agents have a beneficial effect on outcomes in Ramsay Hunt syndrome, despite their widespread use in this condition. The use of these drugs in patients with herpes zoster infections in other parts of the body might suggest that they have a role in herpes zoster oticus. As usual, the absence of positive evidence of benefit (or, in this case, the 'negative' result of one small, statistically under-powered study) does not necessarily indicate that antivirals are ineffective. However, these drugs are associated with a number of adverse effects and this must be taken into consideration when undertaking the requisite risk-benefit analysis before instigating treatment.

Corticosteroids as adjuvant to antiviral treatment in Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults

BACKGROUND

Inflammation and oedema of the facial nerve due to viral infection by the herpes zoster virus are implicated in the aetiology and clinical manifestation of Ramsay Hunt syndrome (herpes zoster oticus with facial palsy). Corticosteroids, with their powerful anti-inflammatory effect, have a potential role to play in the reduction or minimisation of nerve damage when administered together with antiviral therapy, and therefore may improve the outcome for patients with Ramsay Hunt syndrome.

OBJECTIVES

To determine the effectiveness of corticosteroids as an adjuvant to antiviral therapy in adult patients with Ramsay Hunt syndrome (herpes zoster oticus with facial palsy).

SEARCH STRATEGY

We searched the Cochrane ENT Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library Issue 4, 2007), MEDLINE (1950 to December 2007) and EMBASE (1974 to December 2007), CINAHL (1982 to December 2007), LILACS, KoreaMed, IndMed, PakMediNet, ZETOC, Cambridge Scientific Abstracts (Conference Proceedings Database), ISI Proceedings (Web of Science), the National Research Register (NRR), the UK Clinical Research Network Portfolio Database (UKCRN), the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Research Findings Register (ReFeR) and the metaRegister of Controlled Trials (mRCT).

SELECTION CRITERIA

All randomised controlled trials in which corticosteroids (by any route of administration at any dosage) were given as an adjuvant to antiviral agents in the treatment of Ramsay Hunt syndrome.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and trial quality of the available studies, whether they were published or unpublished. No trials were found and therefore no data were analysed.

MAIN RESULTS

This is an empty review as no trials were found that fulfilled the inclusion criteria.

AUTHORS' CONCLUSIONS

Since no randomised controlled trials investigating the use of corticosteroids as an adjuvant to antiviral treatment in Ramsay Hunt syndrome were identified, such studies are needed to assess the effects of such therapy.

Perineal muco-cutaneous herpes zoster treated with brivudin

Herpes zoster results from the reactivation of latent varicella-zoster virus (VZV) from the dorsal root ganglion of sensory nerves. It is rarely described in the pediatric population. We report the case of an 8-year-old immunocompetent boy with a painful lumbosacral herpes zoster that was treated with brivudin and achieved rapid and sustained improvement in the absence of muco-cutaneous or pharmacological side effects.

A case of herpes zoster with abducens palsy

Only a few reports have focused on ocular motor paralysis in herpes zoster ophthalmicus. We report a case of ocular motor paralysis resulting from herpes zoster. The patient, an 80-yr-old woman, presented with grouped vesicles, papules, and crusting in the left temporal area and scalp, with diplopia, impaired gaze, and severe pain. Her cerebrospinal fluid analysis was positive for varicellar zoster virus IgM. Magnetic resonance imaging was performed to rule out other diseases causing diplopia; there were no specific findings other than old infarctions in the pons and basal ganglia. Therefore, she was diagnosed of abducens nerve palsy caused by herpes zoster ophthalmicus. After 5 days of systemic antiviral therapy, the skin lesions improved markedly, and the paralysis was cleared 7 weeks later without extra treatment.

Epidemiology and costs of herpes zoster: background data to estimate the impact of vaccination

In 2004, we conducted a study in Piemonte (Italy), in order to describe incidence, treatment, hospitalizations and costs of herpes zoster (HZ), in population over 14 years of age. Twenty-four regional general practitioners, with 26,394 patients >14 years in charge (0.71% of the regional population), reported prospectively all diagnosed HZ cases. In addition, all regional hospital discharge records were reviewed. Forty-six HZ cases treated at home were reported, accounting for a total incidence of 1.74 cases/1000 population >14 years per year. HZ rate standardized by age on regional population 14 years older is 1.59/1000. The cost per observed home case was 136.06 euros. The incidence of hospital admissions was 0.12/1000 inhabitants. The mean cost of hospitalized cases was 4082.59 euros. These results contribute to depict the impact of HZ in the general population, and to provide background data for setting-up either mathematical models aimed to estimate the impact of vaccination on HZ, and the cost-benefit analyses of various preventive and therapeutic scenarios.

Postherpetic Neuralgia in Older Adults

The purpose of this article is to describe current knowledge and standards of care for postherpetic neuralgia (PHN) among older persons. Three influencing factors are considered: cultural implications, quality of life (QOL), and current practice of alternative/complementary therapy. A review of literature published between 2001 and 2006 was conducted. The findings indicate that PHN has debilitating effects on older adults regardless of culture. The impact of PHN on culture and ethnicity, particularly on the relationship between culture and patient's self-report of herpes zoster and/or PHN, has not been well investigated as evidenced in the literature. PHN is found to be associated with decreased health-related QOL among the elderly, with the most affected domains being sleep, mood, and general activity. Alternative and complementary therapy offers many advantages such as ease of use, availability, and low cost. However, due to lack of controlled trials and insufficient evidence, alternative therapy is not currently used widely and recommended. As the US population ages, the incidence of herpes zoster and PHN is expected to rise. Clinical trials that explore the response of the culturally diverse older adults to current treatment guidelines, strategies for prevention of PHN and its corresponding decrease in QOL, as well as controlled trials of alternative/complementary remedies should be considered.

Recommendations for the management of herpes zoster

The objective of this article is to provide evidence-based recommendations for the management of patients with herpes zoster (HZ) that take into account clinical efficacy, adverse effects, impact on quality of life, and costs of treatment. Systematic literature reviews, published randomized clinical trials, existing guidelines, and the authors' clinical and research experience relevant to the management of patients with HZ were reviewed at a consensus meeting. The results of controlled trials and the clinical experience of the authors support the use of acyclovir, brivudin (where available), famciclovir, and valacyclovir as first-line antiviral therapy for the treatment of patients with HZ. Specific recommendations for the use of these medications are provided. In addition, suggestions are made for treatments that, when used in combination with antiviral therapy, may further reduce pain and other complications of HZ.

Herpes simplex and varicella-zoster virus infections during pregnancy: current concepts of prevention, diagnosis and therapy. Part 2: Varicella-zoster virus infections

Varicella during pregnancy can be associated with severe illnesses for both the mother and her neonate. Varicella pneumonia must be regarded as a medical emergency, since pregnant women are at risk of life-threatening ventilatory compromise and death. After maternal chickenpox in the first and second trimesters, congenital varicella syndrome may occur in nearly 2% of the cases. The characteristic symptoms consist of skin lesions in dermatomal distribution, neurological defects, eye diseases and skeletal anomalies. If the mother develops varicella rashes between day 4 (5) antepartum and day 2 postpartum, generalized neonatal varicella leading to death in about 20% of the cases has to be expected. Normal zoster has not been shown to be associated with maternal pneumonia, birth defects or problems in the perinatal period. On the basis of the clinical consequences of varicella-zoster virus infections during pregnancy, the present paper summarizes the currently available concepts of prevention, diagnosis and therapy.

Cutaneous Infections Associated with HIV/AIDS

With diminished and dysregulated cell-mediated immunity, HIV-infected individuals are susceptible to a myriad of skin infections. These infections include the conditions encountered in immunocompetent patients, as well as infections seen almost exclusively in the setting of HIV infection. The HIV/AIDS pandemic has made some previously rare infections more prominent. Although antiretroviral therapy has been helpful in relieving the burden of cutaneous infections in HIV-infected patients, it does not prevent all opportunistic infections in the skin and also has created new dilemmas.

Le zona et ses complications neurologiques

INTRODUCTION

Herpes zoster is a disease which occurs secondary to the reactivation of varicella-zoster virus (VZV). Its frequency is high in the general population.

STATE OF ART

Herpes zoster leads to numerous complications, among which there were neurological peripheral or central lesions. Antiviral treatment must be instituted, particularly if neurological complications develop, as soon as possible. Corticosteroid therapy can be used, especially in Ramsay-Hunt syndrome or central nervous system involvement.

CONCLUSION

Herpes-zoster is a frequent disease which can lead to serious neurological complications. Early treatment is necessary in order to improve functional outcome.

Linear Darier disease with herpes zoster superinfection treated successfully by brivudine

We report the case of a human immunodeficiency virus-positive patient presenting linear Darier disease with varicella-zoster virus superinfection following the lines of Blaschko. The lesions healed after treatment with brivudine.

Herpes zoster ophthalmicus: presenting as giant-cell arteritis

A 74-year-old woman was referred to the authors' clinic with a 1-week suspicion of giant-cell arteritis. Uncomplicated, bilateral temporal artery biopsies were performed 3 days after admission for therapy. Four hours after the procedure she developed vesicular lesions of the face compatible with herpes zoster ophthalmicus. The temporal artery biopsy revealed perineural lymphocytic aggregation. Both giant-cell arteritis and herpes zoster ophthalmicus form part of the differential diagnosis in elderly patients with headache. In such cases, clues from a temporal artery biopsy may aid in diagnosis of herpes zoster. In addition, the patient in this case developed the rash 10 days after onset of symptoms, which is rare as the average time from onset of symptoms to rash in zoster is 3-5 days.

Actualización en el tratamiento del herpes zóster

The systemic treatment of herpes zoster shortens the healing process, and prevents or alleviates pain and other acute or chronic complications, especially when it is administered in the first 72 hours after symptoms appear. This treatment is especially indicated in patients over the age of 50 and in those who, regardless of age, have head and neck involvement, especially in herpes zoster ophthalmicus. The drugs approved in Europe for the systemic treatment of herpes zoster are aciclovir, valaciclovir, famciclovir and brivudine. Brivudine shows greater effectiveness against the varicella-zoster virus than aciclovir and its derivatives, and can be given just once a day for seven days, compared to multiple doses of the latter. As opposed to the others, brivudine is a non-nephrotoxic drug that should not be administered to immunodepressed patients or to those being treated with 5-fluorouracil. The treatment of herpes zoster to reduce pain should be combined with analgesics and neuroactive agents (amitriptyline, gabapentin, etc). While corticosteroids are of dubious efficacy in the treatment of post-herpes neuralgia, the intensity and duration of the pain can be reduced with some topical treatments (capsaicin, lidocaine patches, etc). Finally, this review discusses treatment guidelines for special locations (cranial nerves) and different subpopulations (children, pregnant women, immunodepressed patients, etc).

Current management of herpes zoster: the European view

The overall incidence of herpes zoster in Europe is approximately 3 per 1000 people per year and more than 10 per 1000 people per year in those aged >80 years. Post herpetic neuralgia (PHN) is a common debilitating complication of herpes zoster, particularly in patients aged >50 years, in persons with severe pain or rash at presentation, and in those with significant prodromal symptoms. Antiviral drugs can effectively control acute symptoms and, if used early enough in the course of the illness, can help prevent the development of PHN and other complications. However, despite this, many patients do not receive such treatment. The economic impact of zoster and PHN is largely underestimated in Europe. Furthermore, there is considerable variation throughout Europe in the management of herpes zoster. Use of antiviral therapy including the newer potent antiviral agents such as brivudin, which requires less frequent administration than acyclovir, is improving patient outcomes in some European countries. However, in many countries, patient awareness of herpes zoster and, as a result, overall antiviral use is low. Guidelines recommending the use of antiviral agents, particularly in patients at risk of developing PHN, are available but are not widely used. More needs to be done to educate the general public and increase awareness among primary healthcare providers of the benefits of timely and appropriate pharmacological therapy in patients with herpes zoster.

Famciclovir

Famciclovir (Famvir) is the oral prodrug of penciclovir, an agent that has demonstrated antiviral activity against herpes simplex viruses, type 1 (HSV-1) and 2 (HSV-2) [which cause orolabial and/or genital herpes simplex], and against varicella zoster virus (VZV) [a reactivation of which leads to herpes zoster]. Famciclovir has efficacy similar to that of aciclovir (in immunocompetent or immunocompromised patients) or valaciclovir (in immunocompetent patients) in the treatment of herpes zoster, and efficacy similar to aciclovir in the treatment of first or recurrent episodes of genital herpes (in immunocompetent or immunocompromised patients). Famciclovir also has efficacy in the suppression of recurrent episodes of genital herpes, and in the treatment of orolabial herpes, in immunocompetent patients. As such, famciclovir is a well tolerated first-line option for the treatment of herpes zoster and the treatment and suppression of genital herpes, and is approved for the treatment of recurrent orolabial herpes. Convenient patient-initiated single-day (for recurrent genital herpes) and single-dose (for orolabial herpes) dosage regimens may contribute to treatment compliance, patient acceptability and subsequent treatment outcomes.

Herpes zoster in the ulnar nerve distribution

Varicella zoster is a ubiquitous virus which usually affects school-aged children as Chicken Pox. While the initial disease is self-limiting and seldom severe, the virus remains in the body. It lies dormant in the dorsal root ganglia and reactivation may occur years later with variable presentations as Herpes Zoster, or Shingles. While Shingles is common, it rarely presents exclusively in the upper extremity. It is important that hand surgeons recognize the possibility of zoster infection, with or without a rash, when evaluating the onset of neuralgia in a dermatomal distribution in the upper limb. Early diagnosis allows rapid and appropriate treatment, with a lower risk of complications. We report on a case of Herpes Zoster isolated to the ulnar nerve distribution in a young woman.

Do herpes zoster patients receive antivirals? A Dutch National Survey in General Practice

BACKGROUND

The main complications of herpes zoster (HZ) are postherpetic neuralgia and, in case of HZ ophthalmicus, eye disorders. Antiviral treatment may modify the course of disease and reduce the risk of complications.

OBJECTIVE

To assess which doctors' and patients' characteristics were related to prescription of antiviral therapy for HZ.

METHODS

Ninety general practices (358 008 patients) in The Netherlands registered all patient contacts in a database for one year as part of the Second Dutch National Survey of General Practice. The present study used ICPC code S70 to search that database for patients with a new diagnosis of HZ. The full-text medical records of the selected patients were then reviewed and the potential determinants for the prescription of antiviral drugs (including characteristics of patients, GPs, and practices) analysed using multilevel logistic regression modelling.

RESULTS

Of the 1129 patients diagnosed with HZ (incidence 3.2/1000 patients/year), 22.5% received antiviral drugs. Independent determinants for prescription of antiviral therapy were age [45-54 years: adjusted odds ratio (OR) 2.9 (95% CI 1.6-5.0); 55-64 years: OR 4.2 (95% CI 2.4-7.6); 65-74 years: OR 5.1 (95% CI 2.7-9.6); > or =75 years: OR 8.1 (95% CI 4.4-15.1)], ophthalmic localisation of the shingles (OR 3.2, 95% CI 1.6-6.7), and the presence of asthma/COPD (OR 1.6, 95% CI 1.0-2.6). GPs who reported to strongly adhere to professional guidelines prescribe more frequently antiviral drugs (OR 1.9, 95% CI 1.2-3.1).

CONCLUSIONS

A minority of HZ patients were prescribed antiviral treatment. Increasing age, ophthalmic localisation, presence of asthma/COPD, and adherence to professional guidelines were factors favouring prescription. More information on the determinants of GPs' treatment decisions is necessary for successful implementation of HZ guidelines.

Fatal varicella zoster virus encephalitis in two patients following allogeneic hematopoietic stem cell transplantation

BACKGROUND

Reduced cellular immunocompetence following allogeneic hematopoietic stem cell transplantation (aHSCT) increases susceptibility to viral infections. Varicella zoster virus (VZV) reactivation in this setting most commonly manifests as dermatomal herpes zoster but in some cases life-threatening VZV encephalitis occurs.

STUDY DESIGN/RESULTS

We describe the cases of two patients who presented with shingles 3 and 18 months, respectively, after HLA-matched peripheral blood stem cell transplantation (PBSCT). Unfortunately, in the further clinical course both patients developed fatal VZV encephalitis, despite initial high-dose intravenous therapy with acyclovir and in one case with additional VZV-immunoglobulin.

CONCLUSION

These two cases suggest that rapid intervention with systemic treatment is warranted and raise the question whether initial combination therapy with intravenous acyclovir and foscarnet, VZV vaccination or long-term low-dose acyclovir are needed to improve treatment and clinical outcome in immunocompromised patients, having undergone allogeneic HSCT.