Severity of skin lesions of herpes zoster at the worst phase rather than age and involved region most influences the duration of acute herpetic pain

Efficacy and Safety of UVA1 Phototherapy Adjunct Treatment for Acute Cutaneous Inflammations and Neuralgia of Herpes Zoster: A Prospective, Randomized, Open-Label, Blinded End-Point Study

Background: Previous case reports hint ultraviolet A1 (UVA1) phototherapy as a novel adjunct treatment for acute cutaneous inflammations and neuralgia of herpes zoster, but its clinical effectiveness and safety in this condition are not yet proven by clinical trials. Objectives: To determine the efficacy and safety of UVA1 phototherapy as an adjunct treatment for acute inflammation and neuralgia in herpes zoster. Methods: A total of 60 patients with moderate-to-severe acute herpes zoster were randomly divided into two parallel groups. Group I received regular treatment and UVA1, and Group II received regular treatment alone. Time of blister crusting and acute erythema subside, assessment of pain, sleep, anxiety, and quality of life were recorded accordingly. Results: In Groups I and II, 28 and 29 patients completed the treatment and follow-up, respectively, with no significant demographic or baseline differences. UVA1 therapy notably reduced blister crusting time and acute erythema subside time and achieved more rapid pain relief within the first 2 weeks. However, it did not significantly alter the rate of postherpetic neuralgia occurrence. Additionally, UVA1 therapy significantly improved anxiety and quality of life scores at the 2-week mark. The primary adverse effects were mild burning and hyperpigmentation at the treatment site. Conclusions: UVA1 phototherapy as an adjunct treatment can expedite the resolution of acute inflammatory cutaneous lesions and neuralgia associated with herpes zoster, providing swifter relief from anxiety and enhancing patient quality of life during the acute phase, with demonstrated good tolerability and safety.

Efficacy and safety of therapies related to acupuncture for acute herpes zoster: A PRISMA systematic review and network meta-analysis

BACKGROUND

Herpes zoster (HZ) is mainly characterized by intense pain and severe skin lesions, particularly during the acute phase, which seriously affects the patient's quality of life. Acupuncture is a widely used and effective treatment for HZ. However, there are many types of acupuncture, which have different curative efficacy. This study employed a network meta-analysis (NMA) to assess and rank the clinical efficacy of different acupuncture therapies.

METHODS

The database of Cochrane Library, Web of Science, PubMed, MEDLINE, Embase, China National Knowledge Infrastructure (CNKI), Chinese BioMedical Database, VIP Database, and Wanfang Database were searched from inception to December 31, 2022 to identify eligible randomized controlled trials (RCTs) of acupuncture related therapies in the treatment of acute HZ. The outcome indicators measured were visual analogue scale (VAS), date of cessation of herpes increase (DCHI), effective rate (ER), postherpetic neuralgia (PHN), and adverse events (AEs). Bayesian network meta-analyses were performed using the GeMTC package (version 1.0-1) and R software (version 4.2.3).

RESULTS

A total of 59 RCTs with 3930 patients were included. The results of this NMA were as follows: compared with pharmacotherapy, electroacupuncture (EA) + pricking and cupping (PC) shown the best efficacy to improve VAS score and reduce DCHI. In terms of ER, EA + fire needle (FN) had the highest results of probability ranking. PC was more effective in reducing the incidence of PHN. Furthermore, this study shown that the incidence of AEs associated with acupuncture-related therapies was acceptable.

CONCLUSIONS

This study indicated that therapies related to acupuncture were both effective and safe in treating acute HZ, and could significantly reduce patients' symptoms such as pain and skin lesions with fewer adverse events. Clinically, the selection of the appropriate therapy should be based on practical considerations. However, due to the limitations of this study, more high-quality trials are required to evaluate the efficacy and safety of acupuncture-related therapy for the treatment of acute HZ.

A Comparison Between Effects of Amenamevir and Famciclovir on Intensities of Acute Pain and the Incidence of Postherpetic Neuralgia in Adult Patients with Herpes Zoster

Objective

Herpes zoster (HZ) is a common disease, whose most common complication is postherpetic neuralgia (PHN). We conducted this study to compare effects of amenamevir (AMNV) and famciclovir (FCV) on intensities of acute HZ pain and the incidence of PHN, which have not been compared yet.

Methods

After approval by the Ethics Committee, we retrospectively investigated adult patients with HZ treated with AMNV or FCV at Juntendo University Hospital between October, 2018 and February, 2020. We compared, between 143 AMNV-treated and 131 FCV-treated patients, pain scores of acute HZ pain evaluated on an 11-point numerical rating scale (NRS) and the incidence of PHN with the Mann-Whitney U test and Pearson's chi-square test, respectively. The univariate logistic regression analysis was used to identify predictors of PHN.

Results

Pain scores during the acute HZ period remained significantly lower in AMNV-treated patients than FCV-treated patients (p = 0.049, 0.011, and 0.016 for Day 3-4, Day 7, and Week 2-3, respectively), although the pain score at Day 0 before treatment didn't differ between them (p > 0.05). The incidence of PHN didn't differ between them (9.8% vs. 11.5%, p > 0.05). In the total cohort, the pain score at Week 2-3 was significantly associated with the development of PHN (r 2 = 0.180, p < 0.00001).

Conclusions

Compared with FCV, AMNV was more effective in reducing acute HZ pain, possibly reflecting its unique mechanism of action. However, AMNV didn't reduce the incidence of PHN possibly due to the multifactorial etiology of PHN.

Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific

Background

Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region.

Methods

We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines.

Results

From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand.

HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation.

Conclusions

Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2198-y) contains supplementary material, which is available to authorized users.

Functional decline and herpes zoster in older people: an interplay of multiple factors

Herpes zoster is a frequent painful infectious disease whose incidence and severity increase with age. In older people, there is a strong bidirectional link between herpes zoster and functional decline, which refers to a decrement in ability to perform activities of daily living due to ageing and disabilities. However, the exact nature of such link remains poorly established. Based on the opinion from a multidisciplinary group of experts, we here propose a new model to account for the interplay between infection, somatic/psychiatric comorbidity, coping skills, polypharmacy, and age, which may account for the functional decline related to herpes zoster in older patients. This model integrates the risk of decompensation of underlying disease; the risk of pain becoming chronic (e.g. postherpetic neuralgia); the risk of herpes zoster non-pain complications; the detrimental impact of herpes zoster on quality of life, functioning, and mood; the therapeutic difficulties due to multimorbidity, polypharmacy, and ageing; and the role of stressful life events in the infection itself and comorbid depression. This model underlines the importance of early treatment, strengthening coping, and vaccine prevention.

Cranial neuralgias

This article describes the clinical findings of cranial neuralgias, such as trigeminal neuralgia, glossopharyngeal neuralgia, nervus intermedius neuralgia, and others, and postherpetic neuralgia. Pathophysiology of these neuralgias, diagnostic methods, and treatment are also discussed. This information will enable the dentist to diagnose patients who have these rare conditions.

Management and prevention of herpes zoster: A Canadian perspective

Varicella-zoster virus reactivation leads to herpes zoster - the main complication of which is postherpetic neuralgia (PHN). Rapid antiviral therapy initiated within 72 h of rash onset has been shown to accelerate rash healing, reduce the duration of acute pain and, to some extent, attenuate the development and duration of PHN. Other adjunctive therapies such as analgesics, antidepressants and some anticonvulsants are frequently required in the management of severe PHN. A live, attenuated zoster vaccine has been recently shown to significantly decrease herpes zoster incidence, PHN and the overall burden of illness when administered to adults older than 60 years of age. This new prophylactic modality has been reported to be cost-effective in the Canadian context, especially in the 60- to 75-year-old age group.

A randomized, placebo-controlled trial of oxycodone and of gabapentin for acute pain in herpes zoster

Although acute pain in patients with herpes zoster can be severe and has a substantial impact on health-related quality of life, there have been no randomized clinical trials of oral medications specifically for its ongoing treatment. A randomized clinical trial was conducted in which 87 subjects >or=50 years of age with herpes zoster within 6 calendar days of rash onset and with worst pain in the past 24h >or=3 on a 0-10 rating scale initiated 7 days of treatment with famciclovir in combination with 28 days of treatment with either controlled-release (CR) oxycodone, gabapentin, or placebo. Subjects were evaluated for adverse effects of treatment, acute pain, and health-related quality of life. The results showed that CR-oxycodone and gabapentin were generally safe and were associated with adverse events that reflect well-known effects of these medications. Discontinuing participation in the trial, primarily associated with constipation, occurred more frequently in subjects randomized to CR-oxycodone (27.6%) compared with placebo (6.9%). Treatment with CR-oxycodone reduced the mean worst pain over days 1-8 (p=0.01) and days 1-14 (p=0.02) relative to placebo but not throughout the entire 28-day treatment period as pain resolved in most subjects. Gabapentin did not provide significantly greater pain relief than placebo, although the data for the first week were consistent with a modest benefit. By demonstrating that CR-oxycodone is safe, generally adequately tolerated, and appears to have efficacy for relieving acute pain, the results of this clinical trial provide a foundation for evidence-based treatment for acute pain in herpes zoster.

The change in zoster-associated pain treated with oral valaciclovir in immunocompetent patients with acute herpes zoster

We have analysed zoster-associated pain treated with valaciclovir (VCV) in immunocompetent patients with acute herpes zoster over 6 months, and evaluated the safety of VCV. We know of no reports that evaluate postherpetic neuralgia (PHN) treated with VCV for 6 months. Predisposing factors that influence PHN were age (over 60 years), clustered vesicles, severity of eruption, sleep disturbance, and hypesthesia. Timing of the administration of VCV before or after the onset of rash did not influence the incidence of PHN. No serious adverse reactions were observed during the administration of VCV.

Postherpetic Neuralgia: The Never-Ending Challenge

Postherpetic neuralgia (PHN) is defined as pain that persists 1 to 3 months following the rash of herpes zoster (HZ). PHN affects about 50% of patients over 60 years of age and 15% of all HZ patients. Patients with PHN may experience two types of pain: a steady, aching, boring pain and a paroxysmal lancinating pain, usually exacerbated by contact with the involved skin. Herpes zoster is initially a clinical diagnosis, based on the observation of a typical dermatomal distribution of rash and radicular pain. HZ is pathologically characterized by inflammatory necrosis of dorsal root ganglia, occasionally associated with evidence of neuritis, leptomeningitis, and segmental unilateral degeneration of related motor and sensory roots. Although acyclovir has been used successfully as standard therapy for varicella zoster virus (VZV) infection in the past decade, resistant strains of VZV are often recognized in immunocompromised patients. Therapy with acyclovir and the use of corticosteroids have been reported to prevent PHN in up to 60% of HZ patients. Management of chronic pain in PHN is more problematic. The only therapy proven effective for PHN in controlled study is the use of tricyclic antidepressants, including amitriptyline and desipramine. There is good evidence of efficacy from randomized trials that gabapentin and pregabalin (new anticonvulsant drugs) are of benefit in the reduction of pain from PHN. As alternative therapies, topical agents such as capsaicin, lidocaine or opioid analgesic treatment may give satisfactory results. Interventions with low risk, such as transcutaneous electrical nerve stimulation (TENS), are appropriate. Evidence is scant for the value of surgical and procedural interventions in general, although there are numerous, small studies supporting the use of specific interventions such as nerve blocks, neurosurgical procedures, and neuroaugmentation. Although antiviral agents are appropriate for acute HZ, and the use of neural blockade and sympathetic blockade may be helpful in reducing pain in selected patients with HZ, there is little evidence that these interventions will reduce the likelihood of developing PHN. Postherpetic neuralgia remains a difficult pain problem. This review describes the epidemiology and pathophysiology of PHN and discusses proposed mechanisms of pain generation with emphasis on the various pharmacological treatments and invasive modalities currently available.

Optimum pain relief with continuous epidural infusion of local anesthetics shortens the duration of zoster-associated pain

OBJECTIVE

To investigate effects of continuous epidural infusion (CEI) of 0.5% bupivacaine added to intermittent epidural boluses (IEB) on the duration of zoster-associated pain (ZAP), as compared with continuous infusion of normal saline placebo added to IEB.

DESIGN

A prospective, double-blind, randomized, placebo-controlled study.

SETTING

A university hospital and an affiliated clinic in Japan from 1996 through 1999.

PATIENTS

56 immunocompetent herpes zoster (HZ) patients, 50 years or older, within 10 days of rash onset and with severe pain and eruption.

INTERVENTIONS

Patients were hospitalized and randomly allocated into 2 groups. CEI group given CEI of 0.5% bupivacaine (0.5-1.0 mL/h) plus IEB of 0.5% bupivacaine 4 times daily (n = 29). IEB group given normal saline infusion plus IEB of 0.5% bupivacaine 4 times daily (n = 27). All patients received oral acyclovir 800 mg, 5 times daily, for 7 days.

OUTCOME MEASURES

The number of days required for complete cessation of ZAP and the proportion of subjects with allodynia beyond 30 days.

RESULTS

The median time to cessation of ZAP was significantly shorter in the CEI group than in the IEB group (29 days vs. 40 days, P = 0.002). The number of patients whose allodynia persisted beyond 30 days of treatment was significantly lower in the CEI group than in the IEB group (10% vs. 37%, P = 0.027).

CONCLUSIONS

CEI of 0.5% bupivacaine plus IEB was associated with a shorter duration of ZAP and fewer patients with allodynia beyond 30 days, compared with IEB plus normal saline infusion. Patients at high risk for developing postherpetic neuralgia (PHN) can be managed with intensive therapies at the early stage of disease, such as CEI, which maintains effective analgesia and may reduce the burden of PHN.

Risk factors for postherpetic neuralgia in patients with herpes zoster

OBJECTIVES

To identify risk factors for postherpetic neuralgia (PHN) using a validated definition of this chronic neuropathic pain syndrome, to determine combinations of risk factors that identify patients with a high risk of developing PHN, and to examine the characteristics of patients with subacute herpetic neuralgia, that is, pain that persists beyond the acute phase of herpes zoster but that resolves before PHN can be diagnosed.

METHODS

The authors examined baseline and follow-up data from 965 herpes zoster patients enrolled within 72 hours of rash onset in two clinical trials of famciclovir.

RESULTS

Univariate and multivariate analyses indicated that older age, female sex, presence of a prodrome, greater rash severity, and greater acute pain severity made independent contributions to identifying which patients developed PHN. Patients with subacute herpetic neuralgia who did not develop PHN were significantly younger and had less severe acute pain than PHN patients but were significantly more likely to have severe and widespread rash than patients without persisting pain.

CONCLUSIONS

The independent contributions to the prediction of PHN made by older age, female sex, presence of a prodrome, greater rash severity, and greater acute pain severity suggest that these risk factors reflect different mechanisms that each contribute to the development of PHN. Subacute herpetic neuralgia that does not progress to PHN may reflect peripheral tissue damage and inflammation caused by a particularly severe or widespread rash.

Cerebrospinal fluid interleukin 8 concentrations and the subsequent development of postherpetic neuralgia

PURPOSE

Other than age, the risk factors for postherpetic neuralgia are not well established. We studied whether the concentration of interleukin 8 in the cerebrospinal fluid is associated with the risk of postherpetic neuralgia.

METHODS

We enrolled 170 patients more than 50 years old who had a typical painful and nontrigeminal herpetic rash. Patients were treated with acyclovir; no corticosteroids were given. Cerebrospinal fluid was taken for analysis of interleukin 8 during and at full crusting of the herpetic rash. Age, sex, comorbid conditions, prodromal pain, localization and severity of herpetic rash, number of skin lesions, and degree of pain were recorded. We used multivariate logistic regression modeling to identify significant predictive factors. Receiver operating characteristic (ROC) curves were evaluated to determine the contribution of each factor.

RESULTS

Six months after healing, 31 patients (18%) had postherpetic neuralgia; 27 patients still had it after 1 year. Only three variables-age (odds ratio [OR] = 2.7 per 10-year increase; 95% confidence interval [CI]: 1.2 to 6.2), acute pain (OR = 1.8 per unit increase in visual analog scale; 95% CI: 1.2 to 2.8), and interleukin 8 concentration in the cerebrospinal fluid at full crusting of the herpetic rash (OR = 1.6 per 20-microg/L increase; 95% CI: 1.3 to 2.0)-were significant predictors of postherpetic neuralgia at 1 year. Interleukin 8 concentration also had the highest area under the ROC curve at these evaluation points (P <0.001).

CONCLUSION

Our results suggest that interleukin 8 concentration in the cerebrospinal fluid at full crusting of herpetic rash may be useful for identifying patients who are likely to develop intractable postherpetic neuralgia.

Factors influencing the features of postherpetic neuralgia and outcome when treated with tricyclics

This paper retrospectively reviews features of postherpetic neuralgia (PHN) in up to 279 personal patients in relation to treatment outcome when treated with tricyclic antidepressants (TCAs). Factors affecting characteristics of PHN: (i) Patients with allodynia (89%) and/or burning pain (56%) have a much higher visual analogue pain intensity score than those without; (ii) Acyclovir (ACV) given for acute shingles (HZ) does not reduce the incidence of subsequent PHN, but reduces the pain intensity in PHN patients with allodynia; (iii) ACV given for acute HZ reduces the incidence of burning pain in subsequent PHN, but not of allodynia; (iv) ACV given for acute HZ reduces the incidence of clinically detectable sensory deficit in subsequent PHN. Factors affecting outcome of TCA-treated PHN: (i) The point in time at which TCA treatment is commenced is by far the most critical factor: started between 3 and 12 months after acute HZ onset, more than two-thirds obtain pain relief (NNT=1.8); between 13 and 24 months, two-fifths (41%) (NNT=3.6); and more than two years, one-third (NNT=8.3). Background and paroxysmal pain disappear earlier and are more susceptible of relief than allodynia. (ii) Twice as many (86%) of PHN patients without allodynia obtain pain relief with TCA treatment than those with (42%); (iii) the use of ACV for acute HZ more than halves the time-to-relief of PHN patients by TCAs; (iv) PHN patients with burning pain are significantly less likely to obtain pain relief with TCAs than those without (p<0.0001).

Rash severity in herpes zoster: correlates and relationship to postherpetic neuralgia

Baseline and follow-up data from 4 samples of immunocompetent patients with herpes zoster who participated in clinical trials of the antiviral agent famciclovir were examined (N = 1778). In both univariate and multivariate analyses, severe rash (ie, >50 lesions, defined as papules, vesicles, or crusted vesicles) was significantly associated with older age, male sex, severe pain, primary involvement of nontrigeminal dermatomes, and a greater number of affected dermatomes. In addition, severe rash predicted the presence of pain 3 months later. The results indicate that severe rash is more common in patients with herpes zoster who are older and who have more severe acute pain and confirm that severe rash is a risk factor for prolonged pain.

Clinical correlates of prolonged pain in Japanese patients with acute herpes zoster

To determine which risk factors are relevant to the occurrence of post-herpetic neuralgia in Japanese patients with acute herpes zoster, correlations between the prolongation of pain and various disease factors were examined in 263 adult patients presenting within 10 days of the onset of rash at 17 institutions in the Hyogo region of Japan. All patients in whom pain persisted for more than 3 months were over 60 years of age. The pain also tended to be more prolonged in those with clustered vesicles, disturbed sleep and hypanaesthesia. Other factors such as underlying disease states, critically involved regions, scar tissue, generalized rash and allodynia were not relevant to the duration of pain. Although decreased pain persistence was observed in patients in whom acyclovir therapy was initiated within 72 h of the onset of symptoms in comparison with those in whom it was initiated after this time, the difference between the two groups of patients was not statistically significant. Our results suggest that advanced age, the presence of clustered vesicles, and disturbed sleep and hypanaesthesia influence the prolongation of herpes zoster pain.

Acute pain in herpes zoster: the famciclovir database project

The results of a considerable number of recent prospective studies have demonstrated that greater acute pain severity in herpes zoster patients is associated with a significantly greater risk of developing postherpetic neuralgia (PHN). Only a few studies have examined the relationships between acute pain severity and demographic characteristics and clinical features of patients with herpes zoster, however, and the results of these studies have been inconsistent. To clarify these relationships, data from 1778 herpes zoster patients studied within 72 h of rash onset in four clinical trials of the antiviral agent famciclovir were examined. Univariate and multivariate analyses indicated that greater acute pain severity was significantly associated with greater age, female sex, greater rash severity, the presence of a prodrome, and primary involvement of non-trigeminal dermatomes. These results demonstrate that three of the established risk factors for PHN - older age, greater rash severity, and the presence of a prodrome - are also associated with more severe acute pain assessed soon after rash onset in patients with herpes zoster. The results of this study are consistent with the recommendation that herpes zoster patients who are older, who have had a prodrome, or who have severe rash or severe acute pain should be targeted for interventions designed to prevent PHN.

A specific thrombin inhibitor, argatroban, alleviates herpes zoster-associated pain

We report the result of a randomized, controlled, open trial of anti-thrombin therapy for herpes zoster-associated pain. Fifty-five herpes zoster patients within 8 days after the onset of skin lesion were enrolled in the trial. Patients were treated with an optimal dose of oral acyclovir (4000 mg/day for 7 days) with or without intravenous administration of a specific anti-thrombin agent, argatroban (10 mg/day, three times a week). Administration of argatroban reduced pain intensity at the 4th through 21st day after the initiation of treatment as determined by visual analogue scale (Mann-Whitney U test, p < 0.05). It also shortened the median time to cessation of analgesic use (14 days vs. 24 days, p = 0.02, logrank test), although it did not significantly reduce the median time to cessation of pain (21 days vs. 43 days, p = 0.07, logrank test). None of the enrolled patients showed evidence of adverse effects including hemorrhagic diathesis. The results suggested that relatively low doses of argatroban are effective in reducing herpes zoster-associated pain. Up-regulation of prothrombin expression by the vascular endothelial and sweat gland epithelial cells in the active skin lesion and transient elevation of plasma thrombin-antithrombin III complex levels in a proportion of patients suggest a lesional generation of thrombin in herpes zoster. This may be relevant to the beneficial effects of the anti-thrombin treatment on the resolution of herpes zoster-associated pain.

Risk and prognostic factors of postherpetic neuralgia and focal sensory denervation: a prospective evaluation in acute herpes zoster ophthalmicus

OBJECTIVES

To determine the general risk and the prognostic factors of postherpetic neuralgia and focal sensory denervation in ophthalmic zoster disease.

STUDY DESIGN

A prospective clinical study.

SETTING

An ophthalmic practice participating in an eye-care network.

PATIENTS

A cohort of 81 immunocompetent adult patients with herpes zoster ophthalmicus and referred by their general practitioner during the acute phase of the disease.

METHODS

Various acute phase clinical parameters were determined via patient history and regular ophthalmic examinations. At a 2-month follow-up, the intensity of postherpetic neuralgia, rated on a 4-point verbal scale, and focal sensory denervation was determined. Skin tactile sensation within the ophthalmic dermatomes was tested with use of a cotton-wool tip, and corneal sensitivity was measured with use of a Cochet-Bonnet esthesiometer by comparing each eye. Statistical analysis was performed via chi2 analysis or Fisher exact test to identify prognostic factors of postherpetic neuralgia and focal sensory denervation at a 2-month follow-up.

RESULTS

At a 2-month follow-up, pain of varying intensity was reported by 38 participants (47%). Of these patients, 25 patients (31%) rated their pain as mild, 8 patients (10%) rated their pain as moderate pain, and 5 patients (6%) rated their pain as severe. At that time, focal loss of normal skin or corneal sensation was detected in 49 patients (60%). Patient age, acute neuralgia score, manifestation and extent of acute skin rash, signs of ocular inflammation, and nontrigeminal cranial nerve involvement were all associated with prolonged pain and tactile sensory loss.

CONCLUSIONS

The severity of acute skin rash, based on a specific manifestation of cutaneous herpes zoster eruptions, and the extent of infection to other neural pathways were clearly associated with postherpetic neuralgia and focal sensory denervation at a 2-month follow-up. These findings suggest that the inability of the immune system to control the spread of replicating varicella-zoster virus in the initial phase of the disease is an important factor in the pathogenesis of chronic zoster-related neuropathy.

Current and Future Management of Herpes Zoster

Herpes zoster (shingles) is a common disease affecting approximately three in 1000 of the population per year and up to 10 in 1000 per year in the elderly population. This incidence is likely to increase as the proportion of elderly people in the general population increases and various forms of immunosuppression become more common, e.g. following organ transplantation. Management of both the acute and chronic pain is probably the most important part of caring for shingles patients. Antiviral therapy, anti-inflammatory steroids and sympathetic nerve blocks are the main measures used during the acute phase to prevent the development of postherpetic neuralgia (PHN). Antiviral agents given early in the acute phase of herpes zoster are generally the therapy of choice and there is also growing evidence for benefit with tricyclic antidepressants. Pain relief once PHN has developed is generally much less effective. Many classes of drug have been investigated for the management of PHN and some have been found to be helpful in some patients. There is as yet no generally effective agent, however preventive antiviral therapy early in the course of herpes zoster is recommended for all elderly patients since they have a high risk of developing severe PHN.