European consensus-based (S2k) Guideline on the Management of Herpes Zoster - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV), Part 2: Treatment

Public health impact of herpes zoster vaccination on older adults in Singapore: a modeling study

In Singapore, population aging and rising life expectancy are increasing herpes zoster (HZ) burden, which may be reduced by vaccination. The present study modeled the public health impact of HZ vaccination in Singapore using ZOster ecoNomic Analysis (ZONA) model adapted with Singapore-specific key model inputs, where available. Base case analysis was conducted in adults ≥ 50 years of age (YOA), exploring three vaccination strategies (no vaccination, recombinant zoster vaccine [RZV], zoster vaccine live [ZVL]) under mass vaccination setting (30% coverage). Scenario and sensitivity analyses were performed. Out of 1.51 million adults in 2021 (base case population), 406,513 (27.0%) cases of HZ, 68,264 (4.5%) cases of post-herpetic neuralgia (PHN), and 54,949 (3.6%) cases of other complications were projected without vaccination. RZV was estimated to avoid 73,129 cases of HZ, 11,094 cases of PHN, and 9,205 cases of other complications over the subjects' remaining lifetime; ZVL would avoid 17,565 cases of HZ, 2,781 cases of PHN, and 1,834 cases of other complications. The number needed to vaccinate to prevent one case of HZ/PHN was lower for RZV (7/41) than ZVL (26/163). Among all five age-stratified cohorts (50-59/60-64/65-69/70-79/≥80 YOA), RZV (versus no vaccination/ZVL) avoided the largest number of cases in the youngest cohort, 50-59 YOA. Results were robust under scenario and sensitivity analyses. Mass vaccination with RZV is expected to greatly reduce the public health burden of HZ among Singapore individuals ≥ 50 YOA. Findings support value assessment and decision-making regarding public health vaccination strategies for HZ prevention in Singapore.

Efficacy and safety of brivudine for the treatment of herpes zoster: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Brivudine has been used in herpes zoster (HZ) treatment for years, but the safety and efficacy of brivudine are inconclusive. Here we perform a meta-analysis to assess the efficacy, safety, incidence of postherpetic neuralgia of brivudine.

METHODS

Data of randomized controlled Trials (RCTS) were obtained from the databases of both English (PubMed, Embase, and Cochrane Library) and Chinese (China National Knowledge Infrastructure, China Science Journal Database, and WanFang Database) literatures from inception to 12 September 2022. Meta-analyses of efficacy and safety of Brivudine for the treatment of herpes zoster for RCTS were conducted.

RESULTS

The analyses included seven RCTS (2095 patients in experimental group and 2076 patients in control group) in the treatment of HZ with brivudine. It suggested that the brivudine group was superior to the control group in terms of efficacy (p = .0002) and incidence of postherpetic neuralgia (p = .04). But the incidence of adverse reactions has no significant difference between the brivudine and the control groups (p = .22). In addition, subgroup analysis of adverse events also showed that brivudine was about the same safety as other modalities in the treatment of HZ (p > .05).

CONCLUSIONS

Brivudine is effective for HZ. However, the evidence on the safety of brivudine is insufficient.

A Retrospective Observation of Gasserian Ganglion Pulsed Radiofrequency Therapy Combined with Low-Dose Morphine Injection in the Treatment of Ophthalmic Herpetic Neuralgia

Purpose

This retrospective study was to investigate the efficacy of Gasserian ganglion pulsed radiofrequency therapy (PRF) combined with low-dose morphine injection in the treatment of refractory ophthalmic herpetic neuralgia.

Patients and methods

A total of 40 intractable ophthalmic herpetic neuralgia patients who received Gasserian ganglion PRF therapy in Pain Department of Nanjing Drum Tower Hospital were retrospectively analysed, with an average age of 70.2 ± 8.5 years and an average disease course of 30 (30, 60) days. According to different interventions, they were divided into two groups: Group A, 19 patients who received Gasserian ganglion PRF therapy combined with 0.2 mg morphine injection via puncture needle; Group B, 21 patients who received only Gasserian ganglion PRF therapy. Data related to the length of hospital stay and associated costs, numerical rating scale scores (NRS), intravenous morphine and oral oxycodone doses during hospitalization, Short form McGill pain questionnaire and Pittsburgh sleep quality index (PSI), and conditions of opioid use and postherpetic neuralgia after discharge were collected in the two groups. SPSS 25.0 was used to perform statistical analysis on data.

Results

The hospital stay, hospitalization costs, and oxycodone dosages for Group A were lower than those for Group B (p = 0.02, p = 0.015 and p = 0.023, respectively). The proportion of patients in group A still taking oral opioids 1 month after discharge and experiencing postherpetic neuralgia 6 months after the onset was lower than that in group B (p = 0.004 and p = 0.049). The NRS upon discharge, as well as the McGill and PSQI scores at the time of discharge and at 1, 3, 6 and 12 months post-discharge, were all significantly reduced compared to those measured upon admission in two groups (p = 0.000).

Conclusion

Gasserian ganglion PRF therapy combined with low-dose morphine injection offers an alternative option for managing intractable herpetic neuralgia and prevention of postherpetic neuralgia in ocular branches.

Clinical Trial Registration

ChiCTR2300073281.

Rare presentation of maxillary osteonecrosis and tooth exfoliation induced by herpes zoster infection in a 29-year-old Chinese male: a case report and literature review

BACKGROUND

We present a case of a 29-year-old male patient without immunodeficiency who suffered from rapid osteonecrosis and tooth exfoliation resulting from herpes zoster (HZ) infection in the left maxillary branch of the trigeminal nerve. Various complications associated with shingles infections have been reported, cases of osteonecrosis and tooth exfoliation due to HZ infection among young people without immunodeficiency are rare. In this case, we focus on the particular manifestation of HZ infection.

CASE PRESENTATION

The patient presented with clusters of erythema and papules, along with non-hemorrhagic blisters on the left face and the loss of the left upper incisor. All lesions were localized to the left side of the face without exceeding the midline. After receiving antibacterial and antiviral treatment, successful control over the infection was achieved; however, he experienced the loss of all upper teeth on the left side except for the first and second upper left molars.

CONCLUSION

This case highlights that rapid osteonecrosis and tooth exfoliation may occur among young individuals without immunodeficiency after HZ infection. HZ infection of the face should be taken very seriously to obtain prompt treatment to prevent the rare complications of bone necrosis and tooth loss as much as possible.

Case report: safety and efficacy of lidocaine infusion for the treatment of intractable zoster-associated neuralgia in solid organ transplant recipients

Introduction

Solid organ transplant recipients are at high risk for developing severe zoster-associated neuralgia, and the pharmaceutic therapies of pain management for these patients with limited organ function are challenging. Intravenous lidocaine infusion showed positive analgesic effects and is used for the management of neuropathic pain. This case series reports the safety and effectiveness of intravenous lidocaine infusion in the treatment of intractable zoster-associated neuralgia in solid organ transplant recipients.

Case series presentation

Five solid organ transplant recipients suffering from refractory zoster-associated neuralgia (numeric rating scale 8-10, despite using high doses of antiepileptic drugs or combined with opioids) were enrolled. Intravenous lidocaine (5 mg/kg ideal bodyweight) was administered over 1.5 h with the monitoring of vital signs. Pain intensity, patient satisfaction, adverse events, typical liver, and kidney function were evaluated. All subjects reported high satisfaction with their treatment and effective pain relief at the 6-month follow-up. One patient experienced short and mild numbness in the mouth and dizziness after the therapy, but no major adverse reactions were reported.

Conclusion

This case series provides evidence that intravenous lidocaine infusion provided effective pain relief as an analgesic treatment option for transplant patients with intractable zoster-associated neuralgia.

Practical Management of the JAK1 Inhibitor Abrocitinib for Atopic Dermatitis in Clinical Practice: Special Safety Considerations

Abrocitinib, an oral, once-daily, Janus kinase (JAK) 1-selective inhibitor, is approved for the treatment of adults and adolescents with moderate-to-severe atopic dermatitis (AD). Abrocitinib has shown rapid and sustained efficacy in phase 3 trials and a consistent, manageable safety profile in long-term studies. Rapid itch relief and skin clearance are more likely to be achieved with a 200-mg daily dose of abrocitinib than with dupilumab. All oral JAK inhibitors are associated with adverse events of special interest and laboratory changes, and initial risk assessment and follow-up monitoring are important. Appropriate selection of patients and adequate monitoring are key for the safe use of JAK inhibitors. Here, we review the practical use of abrocitinib and discuss characteristics of patients who are candidates for abrocitinib therapy. In general, abrocitinib may be used in all appropriate patients with moderate-to-severe AD in need of systemic therapy, provided there are no contraindications, e.g., in patients with active serious systemic infections and those with severe hepatic impairment, as well as pregnant or breastfeeding women. For patients aged ≥ 65 years, current long-time or past long-time smokers, and those with risk factors for venous thromboembolism, major adverse cardiovascular events, or malignancies, a meticulous benefit-risk assessment is recommended, and it is advised to start with the 100-mg dose, when abrocitinib is the selected treatment option.

Efficacy and Safety of Gabapentinoids for Acute Herpes Zoster Neuralgia: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This study aimed to systematically evaluate the clinical efficacy of gabapentin and pregabalin in the treatment of acute herpes zoster (HZ) neuralgia, including pain control and the occurrence of adverse effects.

METHODS

A systematic computerized search was conducted in October 2023 in PubMed, Embase, Web of Science, Cochrane Library, VIP, CNKI, and Wanfang databases. Data from randomized controlled trials (RCTs) comparing gabapentin analogs for the treatment of acute HZ neuralgia were searched. Endpoints were visual analog scores (Visual Analog Scale) and adverse effects at 1, 2, and 4 weeks. Data from studies that met the inclusion criteria were extracted for meta-analysis and sensitivity analysis using Revman 5.4 and Stata16.

RESULTS

The study included 292 patients from 6 RCTs. Of these, 118 were in the gabapentin-treated group, 37 were in the pregabalin-treated group, and 137 were in the placebo-controlled group. The gabapentin group showed superior pain reduction compared with the placebo group ( P < 0.05), but adverse events were more frequent.

CONCLUSION

Gabapentin can effectively reduce acute HZ neuralgia in patients. Pregabalin requires additional RCTs to supplement the analysis.

Herpes Zoster Ophthalmicus: Presentation, Complications, Treatment, and Prevention

Herpes zoster (HZ) is caused by reactivation of latent infection of varicella zoster virus (VZV) in sensory (cranial, dorsal root) ganglia. Major risk factors for HZ are increasing age and immunosuppression. HZ ophthalmicus (HZO) is a subset of HZ with involvement of the ophthalmic division of the fifth cranial trigeminal nerve. Approximately 4-20% of patients with HZ develop HZO. Approximately 50% of patients with HZO develop ocular disease, among whom up to 25% develop chronic or recurrent disease. Common manifestations of ocular disease include conjunctivitis, keratitis, and uveitis, whereas optic neuropathy and retinitis are uncommon. Due to the potential for vision impairment, ocular involvement requires urgent ophthalmic consultation. Early recognition and timely treatment with antivirals may prevent ocular complications. HZO is preventable by vaccination against HZ. Vaccine efficacy/effectiveness studies have been largely conducted for HZ with few studies assessing HZO. Both the recombinant adjuvanted vaccine (RZV) and live-attenuated vaccine (ZVL) significantly reduce the incidence of HZ and HZO in older adults. RZV is more effective than ZVL. Data on the effectiveness of vaccines for prevention of recurrent disease in patients with HZO are limited; however, vaccination is recommended. Despite recommendations to vaccinate individuals likely to benefit from an HZ vaccine, coverage for adults remains suboptimal. Barriers to vaccination include patient beliefs about HZ or HZ vaccines, and factors related to healthcare providers. In particular, the lack of a recommendation from their primary care physician is often cited by patients as a reason for remaining unvaccinated. By encouraging vaccination against HZ, physicians not only prevent HZ and HZO but also potential vision loss due to HZO.Graphical abstract available for this article.

Clinical and demographic profile of herpes zoster ophthalmicus: A hospital-based study of 1752 Indian patients

PURPOSE

To describe the clinical and demographic profile of herpes zoster ophthalmicus (HZO) in patients presenting to a multitier ophthalmology hospital network in India.

METHODS

Cross-sectional hospital-based study included 3,004,470 new patients between August 2010 and October 2021. Patients with a clinical diagnosis of HZO in at least one eye were included. Data were collected using an electronic medical record system.

RESULTS

In total, 1,752 (0.058%) patients were diagnosed with HZO. Nearly two-thirds were male (63.76%) in the seventh decade of life (339;19.35% patients) with unilateral (98.34%) affliction. Higher prevalence was seen in patients from higher socioeconomic status (0.059%) and metropolitan geography (0.062%). Most common ocular signs included eyelid edema (44.19%), conjunctival congestion (65.69%), punctate keratopathy (23.36%), and anterior uveitis (21.22%). Of the 1,781 eyes, mild/no visual impairment was seen in 952 (53.45%) eyes, moderate in 258 (14.49%) eyes, and severe to blindness in 363 (20.39%) eyes. Oral antivirals were started within 72 h (Group A) in 361 (20.61%) patients and after 72 h in 1391 (79.39%) patients (Group B). Significantly lesser severity of ocular involvement was noted in Group A ( P < 0.00001). Surgical intervention was required in 211 (11.85%) eyes.

CONCLUSION

HZO more commonly affects males in the seventh decade of life and is predominantly unilateral. It more commonly affects those from higher socioeconomic strata and metropolitan regions. Half of the eyes have mild or no visual impairment, while others have moderate to severe impairment. Institution of antivirals within 72 h is associated with less severe involvement. Surgical intervention is warranted in a tenth of the eyes.

Antiviral treatment for Ramsay Hunt syndrome: A systematic review and meta-analysis

OBJECTIVE

This study aimed to reveal the efficacy and safety of antivirals in patients with Ramsay Hunt syndrome.

METHODS

A literature search was conducted in PubMed, Ichushi-Web, and Cochrane Central Register of Controlled Trials. Published randomized controlled trials and observational studies, which compared antivirals versus placebo/no treatment for Ramsay Hunt syndrome, were included in the meta-analysis. The primary outcome was non-recovery at the end of the study follow-up. Data was analyzed using Review Manager Software, and pooled odds ratio (OR) with 95 % CI were calculated.

RESULTS

Two randomized controlled trials and 7 cohort studies met the eligible criteria, and 474 individuals were included in the meta-analysis. The OR of antivirals for non-recovery was 0.68 (95 % CI 0.37-1.27, p = 0.22). In subgroup analysis, the OR were 0.48 (95 % CI 0.15-1.61, p = 0.24) in patients with antivirals monotherapy and 0.73 (95 % CI 0.34-1.57, p = 0.42) in patients treated with combination therapy of antivirals and systematic corticosteroid.

CONCLUSION

This systematic review first shows the effectiveness of antivirals. Further study is needed to confirm the efficacy of antivirals.

Perceptions, Attitudes, Beliefs, and Practices Toward Traditional Chinese Medicine Therapies for Herpes Zoster: A Cross-Sectional Study of Healthcare Professionals

Introduction

Traditional Chinese medicine (TCM) holds great potential in promoting healing and relieving pain for herpes zoster (HZ) treatments. Evidence showed that both healthcare professionals' (HCPs) belief and knowledge influence their attitudes, which result in their expression and direct behavior. However, little is known in this area regarding TCM treatments for HZ. This study aimed to understand the HCPs' perceptions, attitudes, beliefs, and practices toward TCM and its services for HZ.

Methods

During July 2021 and October 2022, a cross-sectional study of HCPs querying demographics, perceptions, attitudes, beliefs, and practices toward TCM and TCM services for HZ was conducted. The frequency and percentage or mean and standard deviation were used to present categorical data and continuous data, respectively. A Chi-square analysis compared nurses' and doctors' views on TCM treatments for HZ.

Results

Out of 306 eligible respondents, 66.0% used TCM content in clinical practice less than 40% of the time. Respondents reported that there were three main advantages of TCM for HZ, including better crusting and healing, fewer side effects, and mitigating complications. A total of 41.3% (81/196) of the respondents who had cared for/treated HZ patients applied TCM treatments. The three factors most associated with referrals/providing TCM to patients were postherpetic neuralgia, early erythema or papules, and acute pain. Compared to nurses, doctors showed more endorsement of the efficacy and cost-effectiveness of TCM treatments for HZ patients.

Conclusion

The study found that most healthcare professionals in HZ had a favorable view of TCM, but lacked practical experience administering it to patients. Programs should be developed to provide evidence-based TCM treatments and encourage combining TCM with Western medicine for better patient care.

PROCESS Trial: Effect of Duloxetine Premedication for Postherpetic Neuralgia Within 72 Hours of Herpes Zoster Reactivation-A Randomized Controlled Trial

BACKGROUND

Postherpetic neuralgia (PHN) is the most common chronic complication of herpes zoster (HZ) and results in severe refractory neuropathic pain. This study aimed at evaluating the efficacy of premedication with duloxetine in the prevention of PHN.

METHODS

The PROCESS trial is a multicenter, randomized, open-label, blinded-endpoint trial used a 1:1 duloxetine:control ratio. Adults 50 years or older with HZ who presented with vesicles within 72 hours were recruited. The primary outcome was the incidence of PHN at 12 weeks. PHN was defined as any pain intensity score other than 0 mm on the visual analog scale (VAS) at week 12 after the onset of the rash. The secondary outcomes were the number of participants with VAS >0 and VAS ≥3. The modified intention-to-treat (mITT) principle and per-protocol (PP) principle were used for the primary outcome analysis.

RESULTS

A total of 375 participants were randomly assigned to the duloxetine group and 375 were assigned to the control group. There was no significant difference in the incidence of PHN in the duloxetine group compared with the control group in the mITT analysis (86 [22.9%] of 375 vs 108 [28.8%] of 375; P = .067). PP analysis produced similar results. However, there were significant differences between the 2 groups in the number of participants with VAS >0 and VAS ≥3 (P < .05 for all comparisons).

CONCLUSIONS

Although absolute prevention of PHN does not occur, this trial found that premedication with duloxetine can reduce pain associated with HZ, and therefore can have clinically relevant benefits. Clinical Trials Registration. Clinicaltrials.gov, NCT04313335. Registered on 18 March 2020.

A predictive model of herpes zoster after allogeneic hematopoietic stem cell transplantation: VZV reactivation following antiviral prophylaxis discontinuation

Herpes zoster (HZ) refers to the rash appearing on dermatomes due to varicella zoster virus (VZV) reactivation. The incidence of HZ is significantly higher in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients than in non-HSCT recipients. Although acyclovir prophylaxis is routinely administered to every allo-HSCT recipient for 1 year after transplantation, some individuals eventually develop late-onset HZ after completing prophylaxis. Little information is known about the clinical features of HZ after prophylactic antiviral treatment discontinuation, and an effective predictive model of late-onset HZ needs to be established. A total of 3366 patients who had received allo-HSCT from 2012 to 2017 were included in our study, among whom 201 developed HZ after 1 year (late-onset HZ). We designed a nested case-control study to identify potential predictors of late-onset HZ. Finally, we established a predictive model using binary logistic regression analysis. Age (p < .001), use of immunosuppressants at +1 year (p < .001), CD4-CD8 ratio at +1 year (p < .001), certain mental disorders (depression, anxiety, insomnia and adjustment disorder) (p < .001), engraftment time of neutrophils (p < .001), and CD8+ cell count at +30 days (p < .001) were independent predictors of late-onset HZ. A risk grading system was established based on regression coefficients. Discrimination and calibration analysis indicated that the model had good performance. We also identified several predictive factors of the incidence of HZ-related complications. This is the first scoring system for predicting the incidence of late-onset HZ after allo-HSCT. This model can be applied to identify individuals at high risk of late-onset HZ in the early period after receiving allo-HSCT.

Increasing hospitalisation of patients with herpes zoster ophthalmicus-an interdisciplinary retrospective analysis

BACKGROUND

The occurrence of herpes zoster is rising globally. Future trends will be influenced by changes in population demographics and the growing number of patients at risk. Overall this poses a challenge for healthcare systems.

METHODS

In our interdisciplinary, single-centre retrospective analysis, we aimed to assess the burden of the disease within the Department of Dermatology and the Eye Centre from the Medical Centre, University of Freiburg from 2009-2022. We obtained data from 3034 cases coded using the ICD-10 B02.x. Patients were characterised by sex, age, year of treatment, and type of treatment (inpatient vs. outpatient).

RESULTS

Overall we observed a 200% increase in the number of herpes zoster patients over the 13-year period. Upon closer analysis, this was mainly due to a rise in inpatient treatment for herpes zoster ophthalmicus.

CONCLUSIONS

If the incidence of herpes zoster ophthalmicus continues to increase at the current rate the number of hospitalisations of zoster ophthalmicus would double by 2040, assuming guideline-appropriate treatment. Overall, the results show a growing need for inpatient ophthalmological care.

Practice Patterns in the Initial Management of Herpes Zoster Ophthalmicus in the United States

PURPOSE

The aims of this study were to examine the trends in the initial management of herpes zoster ophthalmicus (HZO) in the United States from 2010 to 2018 and compare them with the treatment preferences of corneal specialists.

METHODS

A retrospective, observational deidentified cohort study was conducted on individuals enrolled in the OptumLabs Data Warehouse who had a new diagnosis of HZO from 1/1/2010 to 12/31/2018. An online survey ascertaining HZO management perspectives was distributed to The Cornea Society listserv. The main outcome assessed was proportion of cases with systemic antiviral prescriptions, eye care provider involvement, and follow-up visits after the initial HZO diagnosis.

RESULTS

Approximately 50% of patients received systemic antivirals the day of initial HZO diagnosis or within 7 days (45.6% and 53.7%, respectively). Most initial diagnoses were made by ophthalmologists (45.0%), followed by optometrists (19.2%). Referral rate to ophthalmology within a year of initial diagnosis was 38.6%. 48.7% cases had at least 1 follow-up visit with any type of provider within 30 days. Our survey of corneal specialists found 97% would prescribe systemic antivirals to those with ocular involvement, but 66% would prescribe antivirals to those without ocular or eyelid involvement. Seventy percent supported all patients having follow-up with an eye care provider within a month.

CONCLUSIONS

HZO antiviral therapies seem to be underprescribed in the United States, referral rates to ophthalmology are low, and follow-up is suboptimal, which are not aligned with recommendations from corneal specialists. More research is needed to establish standardized guidelines for treatment, referral, and follow-up with ophthalmology for HZO.

Efficacy and safety of the recombinant zoster vaccine: A systematic review and meta-analysis

In this systematic review with meta-analysis, the efficacy, effectiveness, and safety of the new GSK recombinant zoster vaccine (RZV) were assessed.Twenty three publications reporting on 14 studies were selected, including 2 pivotal RCTs in older immunocompetent adults (ZOE-50 and ZOE-70), 4 RCTs on immunocompromised patients (haematopoietic stem cell transplantation (HSCT), haematological malignancies, solid tumour, and renal transplantation), and 8 observational studies. Vaccine efficacy of RZV against herpes zoster (HZ) and postherpetic neuralgia (PHN) was very high in immunocompetent older adults (respectively 94% and 91.2% in adults ≥50 years and 91.3% and 88.8% in adults ≥70 years). However, the number needed to vaccinate (NNV) was relatively high (between 32 and 36 for HZ and between 261 and 335 for PHN). Slow waning of the vaccine efficacy has been described after a median follow-up of 10 years after vaccination. In patients after HSCT, vaccine efficacy of RZV against HZ was lower compared to immunocompetent adults (68.2%), while vaccine efficacy of RZV against PHN was similar (89.3%). Higher incidences of HZ and PHN in patients after HSCT resulted in higher absolute reduction of cases and lower NNV (respectively 10 and 115). Observational studies confirmed a good vaccine effectiveness, albeit lower than in RCTs (ranging between 70% and 85%). No safety signal was identified neither in RCTs with immunocompetent or immunocompromised adults nor in observational studies and post-marketing surveillance. Increased reactogenicity after RZV vaccination, limited in extent and duration, did not result in low second dose compliance.

Conclusion

Although vaccine efficacy in RCTs and effectiveness in the real world has been reported to be good, it needs to be stressed that high numbers of immunocompetent adults need to be vaccinated to prevent HZ and PHN. Due to higher incidence, more acceptable NNVs were calculated in immunocompromised adults after HSCT.

The effect of varicella-zoster virus reactivation on the long-term outcomes of patients undergoing allogeneic hematopoietic stem cell transplantation

BACKGROUND

A virus infection may lead the body to produce more immune cells of particular types or stimulate the production of new ones, both of which may have anti-leukemic effects. There has been no research on whether immune cells stimulated by varicella-zoster virus (VZV) infection have anti-leukemic effects. The objective of this investigation is to assess the impact of VZV infection on patients' long-term survival following allogeneic hematopoietic stem cell transplantation (allo-HSCT).

METHODS

This retrospective study investigated the association between varicella-zoster virus (VZV) reactivation and outcomes in 219 individuals who received allogeneic hematopoietic stem cell transplantation (allo-HSCT) at the Sun Yat-sen University's First Affiliated Hospital. According to being diagnosed with VZV infection or not, these patients were grouped into two groups. The comparison of cumulative incidence of relapse, non-recurrent mortality, and overall survival (OS) was conducted between the two groups.

RESULTS

Analyzing multivariate data, VZV reactivation was linked to lower relapse incidence in the group containing all individuals (hazard ratio [HR] = 0.27; 95% confidence interval [CI], 0.12-0.64), patients suffering from acute myeloid leukaemia (HR = 0.10; 95% CI, 0.01-0.83), and patients suffering from acute lymphoblastic leukaemia (HR = 0.25; 95% CI, 0.08-0.77). Moreover, VZV reactivation was linked with decreased non-relapse mortality in all individuals (HR = 0.20; 95% CI, 0.05-0.79), but no statistical significance was found for any disease subgroup. Further, VZV reactivation was an independent predictor for improved OS in the group containing all individuals (HR = 0.10; 95% CI, 0.03-0.29), patients suffering from acute myeloid leukaemia (HR = 0.09; 95% CI, 0.01-0.66), and patients suffering from acute lymphoblastic leukaemia (HR = 0.16; 95% CI, 0.04-0.68).

CONCLUSION

This is the first study to show that VZV reactivation following allo-HSCT is an independent predictor for lower relapse rates and improved OS, providing novel therapeutic approaches to improve patients' long-term survival following allo-HSCT.

Comparison of efficacy of acupuncture-related therapy in the treatment of herpes zoster: A network meta-analysis of randomized controlled trials

OBJECTIVE

A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted to evaluate the efficacy and safety of acupuncture-related therapy in the treatment of herpes zoster (HZ) and to provide a reference for the clinical treatment of herpes zoster.

METHODS

PubMed, Cochrane Library, EMBASE, Web of Science, CNKI, VIP database, Wanfang Database, and SinoMED Chinese and English databases were systematically searched for RCTs on acupuncture-related therapy for HZ until February 2023. Literature screening, data extraction, and risk of bias assessment were performed independently by 2 researchers. R4.2.1 and Stata15.1 software were used for data analysis.

RESULTS

A total of 26 RCTs involving 1929 HZ patients were included, and the network meta-analysis results showed that acupotomy appeared to be most effective in terms of improving VAS scores and the time of incrustation; SUCRA cumulative probability ranking showed the best efficacy of bloodletting in improving efficiency and the time of ceasing new blisters, acupuncture in improving the time of decrustation, and moxibustion in reducing the incidence of postherpetic neuralgia (PHN).

CONCLUSIONS

Through a comprehensive comparison of 9 different acupuncture therapies, acupotomy was the optimal treatment to improve VAS pain scores and the time of incrustation; bloodletting, acupuncture, fire needle, and moxibustion could be effective intervention measures to improve the time of ceasing new blisters and decrustation and reduce the incidence of PHN; Western medicine was closely related to adverse reactions. The conclusions need to be further verified due to the limitations of the study.

Pain Management in Dermatology

BACKGROUND

The dermatologist has to deal with many situations where the patient feels pain and must therefore know how to manage it.

SUMMARY

The aim of this review was to explore the treatments available to manage pain in dermatology in different circumstances, with an emphasis on pharmacological and non-pharmacological interventions specifically studied in dermatology.

Systematic Literature Review of Herpes Zoster Disease Burden in Southeast Asia

INTRODUCTION

Herpes zoster (HZ; i.e., shingles) is caused by the reactivation of varicella zoster virus leading to a painful dermatomal rash. An increasing trend in cases of HZ is evident worldwide; however, there is a lack of comprehensive reviews for Southeast Asian countries.

METHODS

We performed a systematic literature review of articles published until May 2022 that reported HZ epidemiology, clinical management, and health economic data in six Southeast Asian countries: Indonesia, Malaysia, the Philippines, Singapore, Thailand, and Vietnam. Literature searches were conducted in Medline, Scopus, Embase, and gray literature. Articles written in English or local languages were considered for inclusion.

RESULTS

In total, 72 publications were included in the study; 22 were case studies and over 60% originated in Singapore and Thailand. Only two studies (data from Thailand) reported incidence of HZ. The proportion of patients reported with HZ was 0.68-0.7% among dermatology clinics, 0.14% at one emergency department (5.3% of dermatology cases) in Singapore, and 3% of admissions at another hospital in Singapore. Pain was the most common symptom associated with HZ, reported in 74.21-100% of patients. HZ complications were reported in 10.2-21.2% of patients, and the proportions with postherpetic neuralgia and HZ ophthalmicus were 6.3-50% and 4.98-28.57%, respectively. Additionally, there is a lack of comprehensive, up-to-date HZ economic data, with only six studies identified for the Philippines, Singapore, and Thailand.

CONCLUSIONS

Overall, there are limited data reporting incidence and prevalence of HZ in Southeast Asia at a national level. High rates of complications, symptoms, and abundance of case reports suggest substantial healthcare resource utilization for patients with HZ and highlight the need for further research in Southeast Asia assessing the societal impact.

Top 100 Most-Cited Papers in Herpes Zoster from 2000 to 2022: A Bibliometric Study

Background

In recent years, the incidence of herpes zoster has risen steeply, the exact pathogenesis of the acute pain and the transformation into postherpetic neuralgia are still obscure, and the absence of effective management remains a major therapeutic challenge. The purpose of this study was to perform a qualitative and quantitative bibliometric analysis of the 100 most cited papers on herpes zoster.

Materials and methods

Related literature were retrieved from the Web of Science Core Collection. Excel and VOSviewer software were applied to quantitatively analyze, and construct the bibliometric network charts.

Results

The Top 100 most-cited papers published between 2000 and 2018 showed a fluctuating downward trend. The most studies were published in the year of 2000 (n = 12). The article entitled "A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults" from Oxman MN, was the most-cited publication. The United States was the most contributing country, followed by the United Kingdom, and Italy. Finland occupied the highest citations per publication (CPP). The University of Colorado topped the list of institutions with the most publications with 18 articles and also had the most citations (average citations: 281.78 per article). Myron J Levin from the University of Colorado School of Medicine is the most published and most cited researcher overall, whereas Duke University's John W Gnann tops the list in terms of average CPP.

Conclusion

In terms of the quantity of T100 articles, researchers, and organizations, the US is the predominant country. The most T100 papers were published in the special journal Clinical Infectious Diseases. The most academic focus remain the remedies for postherpetic neuralgia and vaccine development for individualized groups.

Pharmacological Treatment of Herpes Zoster and Factors Associated with Its Recurrence

The burden of herpes zoster disease is significant worldwide, with millions affected and an increasing incidence. Increased age and immunosuppression due to disease or drugs have been related to its recurrence. The aim of this work was to determine the pharmacological management of herpes zoster and identify factors associated with recurrence, representing a longitudinal retrospective study identifying the pharmacological management of patients with herpes zoster and the factors related to the first recurrence using a population database. Follow-up was carried out for up to 2 years, and descriptive analysis and Cox proportional hazards regression were performed. A total of 2978 patients with herpes zoster were identified, with a median age of 58.9 years and 65.2% being women. The treatment mainly involved acyclovir (98.3%), acetaminophen (36.0%), and non-steroidal anti-inflammatory drugs (33.9%). A total of 2.3% of patients had a first recurrence. Corticosteroids were used in a greater proportion for recurrence than for the initial herpes episode (18.8% vs. 9.8%, respectively). Being female (HR:2.68;95%CI:1.39-5.17), age ≥60 years (HR:1.74;95%CI:1.02-2.96), having liver cirrhosis (HR:7.10;95%CI:1.69-29.80), and having hypothyroidism (HR:1.99;95%CI:1.16-3.40) were associated with greater probability of a first recurrence. The vast majority of patients were managed with acyclovir, and the use of acetaminophen or non-steroidal anti-inflammatory drugs for pain management was frequent. Several conditions were found that increased the probability of presenting a first recurrence of herpes zoster, such as age over 60 years, being a woman, suffering from hypothyroidism, and liver cirrhosis.

Pain Fluctuations of Women with Subacute Herpetic Neuralgia During Local Methylcobalamin in Combination with Lidocaine Treatment: A Single-Blinded Randomized Controlled Trial

Purpose

To evaluate the efficacy and pain fluctuations of methylcobalamin in combination with lidocaine local injection treatment for subacute herpetic neuralgia (SHN).

Methods

Seventy-nine women (60.4 ± 2.7 years) with thoracic SHN were enrolled and randomized to receive a combination of methylcobalamin and lidocaine local injection (MI, N=40), or a combination of lidocaine patch 5% and oral methylcobalamin (PO, N=39) for four weeks. Repeated-measures analyses of variance were used to evaluate the effect on pain levels. Generalized estimation equations were used to analyze the cause-effect relationship between pain fluctuations and influencing factors.

Results

At the treatment endpoint, the group, treatment time, and group interacted with treatment time effects of the pain scores and area were statistically significant (P<0.001), The pain scores were 2.9 ±0.9 (MI) and 4.3 ± 1.5 (PO). 80.00% (MI) or 28.21% (PO) of patients had pain scores ≤ 3, the odds ratio was 2.84 (95% CI: 1.68 to 4.79). The incidence of postherpetic neuralgia was 5.0% (2/40) at 3 months. Pain fluctuated repeatedly during treatment. The pain fluctuation increased from 8.75 log folds in the afternoon, to 79.85 log folds at night. With the ADLs level increasing from 1 to 3, the pain fluctuated from 4.28 to 17.70 log folds. Allodynia, itching, sleep quality, and ADLs were the significant influencing factors (P<0.05).

Conclusion

This study validated the efficacy of methylcobalamin combined with lidocaine for SHN, and confirmed that pain levels in patients with SHN had an obvious circadian rhythm. ADLs were an important cause of pain fluctuations.

Current scenario and future applicability of antivirals against herpes zoster

Herpes zoster (HZ) is a common disease in the aging population and immunocompromised individuals, with a lifetime risk of 20%-30% that increases with age. HZ is caused by reactivation of the varicella-zoster virus (VZV), which remains latent in the spinal dorsal root ganglia and cranial sensory ganglia after resolution of the primary VZV infection. The main focus of HZ management is rapid recovery from VZV infection as well as the reduction and prevention of zoster-associated pain (ZAP) and postherpetic neuralgia (PHN). The use of antivirals against VZV is essential in the treatment of HZ. However, limited antivirals are only licensed clinically for the treatment of HZ, including acyclovir, valacyclovir, famciclovir, brivudine, and amenamevir. Fortunately, some new antivirals against different types of Herpesviridae have been investigated and suggested as novel drugs against VZV. Therefore, this review focuses on discussing the difference in efficacy and safety in the currently licensed antivirals for the treatment of HZ, the applicability of future novel antivirals against VZV, and the preventive or therapeutic effects of these antivirals on ZAP or PHN.

Investigating the Therapeutic Effect of Intradermal Acupuncture for Acute Herpes Zoster and Assessing the Feasibility of Infrared Thermography for Early Prediction of Postherpetic Neuralgia: Study Protocol for a Randomized, Sham-Controlled, Clinical Trial

Introduction

Herpes zoster (HZ) can adversely influence patients' quality of life and sometimes it can develop postherpetic neuralgia (PHN). To date, it remains challenging to be managed by currently available therapies. Intradermal acupuncture (IDA) has the potential to be an adjunctive therapy for acute HZ and infrared thermography (IRT) may be useful for predicting PHN; however, current evidence remains inconclusive. Therefore, the purposes of this trial are to 1) evaluate the efficacy and safety of IDA as an adjunctive therapy for acute HZ; 2) to explore the feasibility of IRT for early prediction of PHN and as an objective tool to aid in subjective pain assessment in acute HZ.

Methods

This study is designed as a randomized, parallel-group, sham-controlled, and patient-assessor-blinded trial, including 1-month treatment and 3-month follow-ups. Seventy-two qualified participants will be randomly split into the IDA or sham IDA group in a ratio of 1:1. Apart from standard pharmacological treatments in both groups, the two groups will receive 10 sessions of IDA or sham IDA, respectively. Primary outcome measures are the visual analog scale (VAS), indicators of herpes lesions' recovery, the temperature of the pain area, and the incidence rate of PHN. The secondary outcome is the 36-item Short Form Health Survey (SF-36). Indicators of herpes lesions' recovery will be assessed at each visit and follow-ups. The remaining outcomes will be assessed at baseline, 1 month after intervention, and 3-month follow-up. Safety evaluation will be determined by adverse events during the trial.

Conclusion

Expected results will determine whether IDA can enhance therapeutic effectiveness of pharmacotherapy for acute HZ with acceptable safety profile. In addition, it will verify the accuracy of IRT for early prediction of PHN and as an objective tool of subjective pain for acute HZ.

Trial Registration

Clinicaltrials.gov (identification number: NCT05348382; Registered 27 April 2022, https://clinicaltrials.gov/ct2/show/NCT05348382).

Ramsay Hunt syndrome and mandibular alveolar bone necrosis following herpes zoster: A case report and literature review

Background

Reactivation of latent varicella-zoster virus (VZV) can induce herpes zoster (HZ). Ramsay Hunt syndrome (RHS) occurs through the reactivation and proliferation of VZV in the geniculate ganglion, which can lead to vesicular rash in the ear or oral mucosa, accompanied by neurological disorders.

Materials and methods

A 50-year-old man sought a remedy for pain in the right ear and face. Within 1 week, all his lower right teeth fell out, and in the following 3 months, his lower right mandibular alveolar bone gradually became necrotic. In the past 20 days, he experienced blister rash, hearing and taste loss, and slight facial paralysis.

Results

After ruling out tumors and other infectious diseases, he was diagnosed with trigeminal HZ and RHS.

Conclusion

Ramsay Hunt syndrome with tooth loss and alveolar osteonecrosis is rare. It requires long-term treatment of pain, and prevention and treatment of tooth loss and alveolar bone necrosis are difficult and warrant further study.

Beinschmerz – dermatologische Ursachen

Einleitung Als Grund für akute oder chronische Beinschmerzen werden oft vaskuläre Erkrankungen vermutet. Es stellt sich die Frage, ob auch dermatologische Krankheiten mit Beinschmerzen einhergehen.

Methode Dermatologische Krankheitsbilder werden hinsichtlich einer begleitenden oder kausalen Schmerzhaftigkeit systematisch dargestellt.

Ergebnisse Bei Infektionserkrankungen der Haut steht der Schmerz im Vordergrund, allergische oder toxische Kontaktdermatitiden, Juckreizerkrankungen sowie kutane Autoimmunerkrankungen gehen mit Schmerzen einher.

Zusammenfassung Bei unklaren Beinschmerzen sollte auch an eine zugrundeliegende dermatologische Erkrankung gedacht werden. Der Schmerz kann als Prodromalsymptom bei Herpes zoster auftreten.

Analysis of Efficacy and Factors Associated with Reccurence After Radiofrequency Thermocoagulation in Patients with Postherpetic Neuralgia: a Long-Term Retrospective and Clinical Follow-Up Study

INTRODUCTION

Postherpetic neuralgia (PHN) is a painful condition that persists for 1 month or more after herpes zoster rash has healed. Radiofrequency thermocoagulation (RF-TC) provides analgesia by destroying the dorsal root ganglion and blocking the pain upload pathway; nonetheless, the concomitant neurological-related side effects and recurrence remain a concern.

METHODS

In this study, 228 patients with PHN in the thoracic segment treated with RF-TC of the dorsal root ganglion of the spinal nerve were included, and were followed up regularly after surgery. The numerical rating scale (NRS) scores, time to recurrence, and intraoperative and postoperative adverse events were recorded and analyzed. The Kaplan-Meier method was used to plot survival curves and calculate the cumulative effective rate and recurrence rate. Cox regression analyses were performed to identify factors associated with postoperative recurrence. Predictive models were built to assess the value of applications.

RESULTS

The NRS scores decreased in all postoperative periods compared with preoperative ones. At 10-year-follow-up, recurrence was observed in 34.6% (79/228) of patients that underwent PHN. The main postoperative complications were numbness and reduced abdominal muscle strength, which gradually decreased with time, while the abdominal muscle strength gradually recovered. No other adverse events occurred. Interval-censored multivariable Cox regression analysis demonstrated that disease course, complications, pain grade, and type of RF electrode were associated with a significantly higher risk of relapse. The main intraoperative adverse effect was a transient increase in pain during RF-TC.

CONCLUSION

CT-guided RF-TC of the dorsal root ganglion of the spinal nerve for PHN is a relatively safe and effective surgical option. Disease course, type of RF electrode, complications, and pain grade are risk factors for postoperative recurrence and can assist in clinical decision-making before the RF-CT procedure.

Fire Needling Acupuncture for Adult Patients with Acute Herpes Zoster: Protocol of a Systematic Review and Meta-Analysis

Background

Acute herpes zoster (HZ) is characterized as a vesicular rash with unilateral distribution produced by the reactivation of varicella zoster virus. It can induce various comorbidities that can adversely influence the quality of life of patients. The purpose of this systematic review is to assess the effect and safety of fire needling acupuncture on acute HZ.

Methods

Three English databases (PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials) and four Chinese Databases (China National Knowledge Infrastructure, Wanfang database, Chongqing VIP database, and China Biology Medicine database) will be searched from their inceptions to July 2022. Randomized controlled trials investigating fire needling acupuncture therapy for acute HZ will be included, regardless of publication status. Two reviewers will independently conduct the study screening, data extraction, and research quality assessments. The primary outcome measures are the Pain Visual Analogue Scale and the occurrence of postherpetic neuralgia. Secondary outcomes measures are the evaluation of skin lesions, time to resolution of pain, tolerance evaluation, total effective rate, adverse events and changes in inflammatory and immune suppression markers in peripheral plasma. All included studies will be assessed for methodological quality via the Cochrane Collaboration’s bias risk assessment tool. Meta-analyses will be undertaken using Review Manager V.5.3 software. The findings will be reported as the risk ratio of the binary data and the mean difference (MD) or standardized MD of the continuous data. Subgroup analyses and sensitivity analyses will be conducted where appropriate. The Grading of Recommendations Assessment, Development, and Evaluation will be used to assess evidence certainty.

Results

From the study, we will ascertain the effects and safety of fire needling acupuncture on acute HZ.

Conclusion

This study will validate the effects and safety of fire needling acupuncture in the management of acute HZ, generating new evidence to guide acupuncture interventions for acute HZ in the future.

Registration Number

PROSPERO CRD42020199047.

Vaccination for herpes zoster in patients with solid tumors: a position paper on the behalf of the Associazione Italiana di Oncologia Medica (AIOM)

Herpes zoster (HZ) is the infectious reactivation of the varicella-zoster virus. HZ is more frequent in immunocompromised subjects, including patients with cancer. HZ complications can even last for years with a consequent delay in treatment of the underlying malignancy and with an unfavorable impact on quality of life. Nowadays, HZ is a vaccine-preventable disease: the recent approval of adjuvanted glycoprotein E-based recombinant zoster vaccine has changed preventive perspectives in immunocompromised subjects. Recombinant zoster vaccine induced both strong humoral and cellular immune responses also in immunocompromised patients. The question is, therefore, to which categories of cancer patients we should recommend HZ vaccination. Based on a careful review of the available data present in the literature, including recommendations and expert opinions, we report the position of the Associazione Italiana di Oncologia Medica on HZ vaccination in adult patients with solid tumors, thus providing clinical practice advice in a field where clear-cut information is missing.

•

Herpes zoster (HZ) is a vaccine-preventable disease.

•

The vaccination may prevent severe HZ complications and bacterial superinfections.

•

The recombinant vaccine (RZV) is safe and efficacious in frail subjects.

•

RZV can be co-administered, at different anatomic sites, with other vaccines.

Ultrasound-Guided Stellate Ganglion Block Combined with Extracorporeal Shock Wave Therapy on Postherpetic Neuralgia

OBJECTIVES

To evaluate the effect of ultrasound-guided stellate ganglion block combined with extracorporeal shock wave therapy (ESWT) on postherpetic neuralgia.

METHODS

Thirty-six patients with craniofacial postherpetic neuralgia, whose skin lesions were healed and natural course more than 1 month, were selected for the study and then randomly divided into 3 groups: the ultrasound-guided stellate ganglion block group (group A, n = 12), the extracorporeal shock wave therapy group (group B, n = 12), and the combined treatment group (group C, n = 12). Each group received basic drug treatment. The Visual Analogue Scale (VAS) and the Pain Disability Index (PDI) were used to evaluate the clinical effects of the 3 groups of patients before treatment, after twice treatments, after treatment for four times, and after treatment for six times.

RESULTS

The VAS and PDI were significantly declined in each group after the treatment (P < 0.05), and the declination in group C was more obvious than the other two groups (P < 0.05). After treatment for six times, the VAS score of group A, group B, and group C was 3.1 ± 1.2, 3.3 ± 1.3, and 1.9 ± 0.7, respectively. After treatment for six times, the PDI of group A, group B, and group C was 11.7 ± 8.4, 12.3 ± 7.8, and 4.6 ± 3.2, respectively. Three patients developed skin bruising and slight swelling, which were relieved by themselves.

CONCLUSIONS

Ultrasound-guided stellate ganglion block combined with shock wave therapy could significantly improve the pain symptoms of patients with postherpetic neuralgia, which is a safe and effective treatment for postherpetic neuralgia.

[Herpes zoster-prevention, diagnosis, and treatment]

BACKGROUND

Herpes zoster (HZ) is a common skin disease resulting from a regionally limited reactivation of a latent infection with the varicella zoster virus (VZV). Despite its usually self-limiting course, HZ is associated with a considerable individual and public health burden of disease, particularly due to its high rate of postherpetic neuralgia (PHN).

OBJECTIVES

To improve knowledge of the current recommendations for the prevention, diagnosis and treatment.

MATERIALS AND METHODS

Narrative review and summary of current guideline recommendations.

RESULTS

In Germany, the recombinant VZV subunit zoster vaccine is recommended for all adults of 60+ years and for immunocompromised persons of 50+ years. The diagnosis of HZ is clinical; in case of uncertainty, laboratory investigations can help confirm the diagnosis. For patients with HZ ophthalmicus, HZ oticus or neurological complications, an interdisciplinary approach is advantageous. Antiviral treatment should be started as early as possible; various factors, including the duration and location of the disease, the patient's age and signs of a complicated course, serve to determine the indication to initiate an antiviral medication. The choice of the appropriate treatment depends, among other factors, on the intravenous availability, comorbidities and intake preferences. Early and sufficient analgesic treatment according to the WHO pain ladder and, if required, with anticonvulsant adjuvants is necessary to treat acute pain and to reduce the risk for PHN.

CONCLUSION

Implementation of the current recommendations for the prevention, diagnosis and treatment of HZ and PHN is important to reduce the high burden of disease and improve quality of life of the patients.

Acute herpes zoster radiculopathy mimicking cervical radiculopathy after ChAdOx1 nCoV-19/AZD1222 vaccination

This case report describes an 84-year-old man who presented with 3 weeks of gradually worsening right arm weakness associated with a painful vesicular rash across his arm. This occurred 3 days after his first dose of the ChAdOx1 nCoV-19/AZD1222 (University of Oxford, AstraZeneca and the Serum Institute of India) vaccine. The diagnosis was complicated by the presence of right C5–C6 foraminal stenosis compressing on the C6 nerve root sheath on non-contrast MRI, leading to an initial diagnosis of cervical radiculopathy. However, a positive varicella zoster virus-PCR test and findings of abnormal contrast enhancement of his right C5–C7 nerve roots on gadolinium-enhanced MRI resulted in a revision of his diagnosis to zoster radiculopathy. He was subsequently commenced on oral valacilovir and made significant recovery. This report aims to highlight the diagnostic dilemma between cervical radiculopathy secondary to spondylosis and zoster radiculopathy and how an erroneous diagnosis could result in inappropriate, aggressive surgical intervention and delayed treatment with antiviral therapy.

Sudden Onset of Unilateral Facial Paralysis with Ear Pruritus: A Quiz

Abstract is missing (Quiz)

Management of herpesvirus reactivations in patients with solid tumours and hematologic malignancies: update of the Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO) on herpes simplex virus type 1, herpes simplex virus type 2, and varicella zoster virus

Clinical reactivations of herpes simplex virus or varicella zoster virus occur frequently among patients with malignancies and manifest particularly as herpes simplex stomatitis in patients with acute leukaemia treated with intensive chemotherapy and as herpes zoster in patients with lymphoma or multiple myeloma. In recent years, knowledge on reactivation rates and clinical manifestations has increased for conventional chemotherapeutics as well as for many new antineoplastic agents. This guideline summarizes current evidence on herpesvirus reactivation in patients with solid tumours and hematological malignancies not undergoing allogeneic or autologous hematopoietic stem cell transplantation or other cellular therapy including diagnostic, prophylactic, and therapeutic aspects. Particularly, strategies of risk adapted pharmacological prophylaxis and vaccination are outlined for different patient groups. This guideline updates the guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Medical Oncology (DGHO) from 2015 "Antiviral prophylaxis in patients with solid tumours and haematological malignancies" focusing on herpes simplex virus and varicella zoster virus.

Herpes zoster in patients with solid tumors treated with immune checkpoint inhibitors

Tweetable abstract

Herpes zoster (HZ) is a vaccine-preventable disease, but the role of the vaccine in cancer patients during immunotherapy (ICIs) is still unknown. The clinical and economic consequences of HZ and the increased use of ICIs require a greater awareness by the oncologist.

Chronic pain and infection: mechanisms, causes, conditions, treatments, and controversies

Throughout human history, infection has been the leading cause of morbidity and mortality, with pain being one of the cardinal warning signs. However, in a substantial percentage of cases, pain can persist after resolution of acute illness, manifesting as neuropathic, nociplastic (eg, fibromyalgia, irritable bowel syndrome), or nociceptive pain. Mechanisms by which acute infectious pain becomes chronic are variable and can include immunological phenomena (eg, bystander activation, molecular mimicry), direct microbe invasion, central sensitization from physical or psychological triggers, and complications from treatment. Microbes resulting in a high incidence of chronic pain include bacteria such as the Borrelia species and Mycobacterium leprae, as well as viruses such as HIV, SARS-CoV-2 and herpeses. Emerging evidence also supports an infectious cause in a subset of patients with discogenic low back pain and inflammatory bowel disease. Although antimicrobial treatment might have a role in treating chronic pain states that involve active infectious inflammatory processes, their use in chronic pain conditions resulting from autoimmune mechanisms, central sensitization and irrevocable tissue (eg, arthropathy, vasculitis) or nerve injury, are likely to cause more harm than benefit. This review focuses on the relation between infection and chronic pain, with an emphasis on common viral and bacterial causes.

Clinical Management of Herpes Zoster in Patients With Rheumatoid Arthritis or Psoriatic Arthritis Receiving Tofacitinib Treatment

Introduction

Risk of herpes zoster (HZ) is increased with Janus kinase inhibitor use. We evaluated clinical study data relating to HZ management in patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) receiving tofacitinib.

Methods

This post hoc analysis included data from 21 RA and 3 PsA clinical studies; data were pooled for tofacitinib doses. Outcomes of HZ events (serious and non-serious) and tofacitinib treatment changes were evaluated in response to first and second HZ events. Median time to resolution was stratified by dermatomal involvement, history of HZ prior to tofacitinib, changes to tofacitinib treatment, anti-viral and corticosteroid use, and tofacitinib dose.

Results

Seven hundred eighty-three (11.1%, N = 7061) patients with RA experienced ≥ 1 HZ event, 63 (8.0%) of whom had ≥ 2 HZ events. In patients with PsA, 36 (4.6%, N = 783) experienced ≥ 1 HZ event, 1 (2.8%) of whom had ≥ 2 HZ events. For most HZ events, tofacitinib treatment was unchanged or temporarily discontinued. The majority of patients received anti-viral treatment, most within 3 days of onset. Post-herpetic neuralgia developed in 6.9% and 3.2% of patients with RA with first and second events, respectively, and in 2.8% of patients with PsA with a first event. Most first and second events resolved (RA: 97.6% and 96.8%, respectively; PsA: 94.4% and 100%, respectively). Median time to resolution was 22.0 days for first and 15.0 days for second events for RA and 20.5 days for first and 11.0 days for second events (n = 1) for PsA. Time to resolution of first events for RA and PsA was generally numerically shorter for patients with single dermatomal HZ, history of HZ, or anti-viral use versus those without.

Conclusion

Among patients receiving tofacitinib, recurrent events were more common in patients with RA versus PsA; HZ duration was shorter for repeat events.

Trial Registration

NCT01262118, NCT01484561, NCT00147498, NCT00413660, NCT00550446, NCT00603512, NCT00687193, NCT01164579, NCT00976599, NCT01059864, NCT01359150, NCT02147587, NCT00960440, NCT00847613, NCT00814307, NCT00856544, NCT00853385, NCT01039688, NCT02187055, NCT00413699, NCT00661661, NCT01877668, NCT01882439, NCT01976364.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00390-0.

Patients with rheumatoid arthritis (RA) or psoriatic arthritis (PsA) have weakened immune responses and are more likely to get herpes zoster (HZ; also known as shingles) infections compared with the general population. Patients who receive treatments for RA or PsA that have an effect on their immune system are more likely to get HZ. Here, we assessed how common HZ was in patients with RA or PsA who were given tofacitinib during clinical trials, the management of these infections, and how this affected the course of the infection. Approximately 1 in 10 patients with RA and 1 in 20 patients with PsA had HZ. Of those patients who had HZ, 1 in 12 with RA and 1 in 36 with PsA were infected again at a later point. A small number of patients also had long-lasting pain after HZ infection. When patients had a HZ infection, most either continued treatment with tofacitinib or paused treatment for a period of time. Pausing or continuing treatment did not appear to affect how long the infection lasted or whether patients had another infection. Most patients received treatment for HZ infection, and patients who were treated had shorter infections. In most patients, infections cleared up and were more likely to clear up more quickly when patients had HZ previously.

Analgesic Effect of Electroacupuncture on Postherpetic Neuralgia: A Trial Protocol for a Multicenter Randomized Controlled Trial

INTRODUCTION

The chronic neuropathic pain associated with postherpetic neuralgia (PHN) can last for several months or even many years, seriously affecting the affected person's work, sleep, mood, and daily life activities. In generaly, current treatments for PHN are at best limited and unsatisfactory, and adverse reactions are common, especially in elderly patients. Electroacupuncture (EA) is widely used clinically to manage painful diseases, but there remains a lack of evidence to support the effectiveness of EA on PHN. This study is designed to assess the efficacy and safety of EA on PHN, and to provide evidence-based medical evidence for EA treatment of PHN.

METHODS

This multicenter, prospective, randomized controlled trial will recruit 448 patients with PHN at seven clinical centers. Multicenter stratified variable block randomization will be used, and the eligible patients will be randomly allocated in a ratio of 1:1 to the EA group or sham EA group. The EA group will receive 4 weeks of EA treatment, given as 30-min treatment sessions, once daily, 5 times per week, for a total of 20 treatments; the sham EA group will receive sham EA treatment under the same conditions.

PLANNED OUTCOMES

The primary outcome measure is the 11-point Numeric Rating Scale pain score at week 4. The secondary outcome measures, including mechanical pain threshold, pain area of PHN, average number of pain episodes, the short-form McGill Pain Questionnaire 2, Zoster Brief Pain Inventory, the Depression, Anxiety, and Positive Outlook Scale, Patient Global Impression of Change, safety of EA, and use of concomitant medications, among others. The primary analysis of the outcomes will be the mixed-effect model with repeated measurement between groups on an intent-to-treat population.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT04560361. Registered 23 September 2020 ( https://clinicaltrials.gov/ct2/show/NCT04560361?term=NCT04560361&draw=2&rank=1 ).

Herpes-zoster-Update – was gibt es Neues?

Shingles are triggered by the reactivation of an infection with the varicella zoster virus (VZV) and are characterized by specific vesicular skin lesions. Mostly, elderly patients are affected. Depending on the affected dermatome, some serious complications can be observed. The introduction of a vaccine against shingles in Germany offers a great potential for reducing the frequency and severity of this disease. There are both a live vaccine, which is no longer recommended, and an inactivated vaccine, which, however, is still not sufficiently recommended to the authorized patient groups and is also only available to a limited extent due to delivery bottlenecks. HZ neuralgia is a serious complication of the disease that requires rapid and effective therapy and should be handed over to experienced pain therapists rather too early than too late. Unfortunately, in everyday clinical practice only a few people are familiar with VZV vasculopathy, which is associated with a significantly increased risk of cerebral insults.

Risk of herpes zoster associated with biological therapies for psoriasis and psoriatic arthritis: A systematic review and meta-analysis

BACKGROUND

Biological therapy is effective for the treatment of psoriasis and psoriatic arthritis; however, adverse effects related to immunosuppression, such as viral infections, have been reported. Amongst these infections, herpes zoster (HZ) is common.

OBJECTIVE

To evaluate the risk of HZ in psoriasis and psoriatic arthritis patients treated with biological therapy.

DATA SOURCES

A comprehensive literature search of PubMed, Embase, and Web of Science was performed using certain keywords until October 9, 2020. Nine studies were included after a detailed assessment.

STUDY ELIGIBILITY CRITERIA

The eligibility criteria included randomized controlled trials (RCTs) and observational studies of patients with psoriasis or psoriatic arthritis treated with biological therapies; compared with non-biological therapies, non-biological systemic therapies, or controls; with the incidence of HZ reported in case and control groups. The Cochrane risk of bias tool and Newcastle-Ottawa scale were used to assess the quality of the RCTs and observational studies, respectively. Data were extracted from 9 eligible studies and then analyzed using Stata software (Version 12.0).

RESULTS

The risk of HZ in biological therapies was higher than that in non-biological (odds ratios [OR]: 1.48; 95% confidence interval [CI]: 1.18-1.86; I2 = 0%) and non-biological systemic (OR: 1.32; 95% CI: 1.02-1.71; I2 = 0%) therapies. Furthermore, the risk of HZ associated with tumor necrosis factor-α inhibitors increased significantly (OR: 1.50; 95% CI: 1.11-2.02; I2 = 0%). Notably, infliximab (OR: 2.43; 95% CI: 1.31-4.50; I2 = 0%) and etanercept (OR: 1.65; 95% CI: 1.07-2.56; I2 = 0%) increased the risk of HZ, while adalimumab (OR: 1.21; 95% CI: 0.64-2.30; I2 = 0%), ustekinumab (OR: 2.20; 95% CI: 0.89-5.44; I2 = 0%), alefacept (OR: 1.46; 95% CI: 0.20-10.47; I2 = 0%), and efalizumab (OR: 1.58; 95% CI: 0.22-11.34; I2 = 0%) did not.

LIMITATIONS

Few RCTs have reported HZ incidents; thus, our results require confirmation via large-scale RCTs.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Biological therapies, especially tumor necrosis factor-α inhibitors, may lead to the risk of HZ in psoriasis and psoriatic arthritis patients. Amongst these agents, infliximab and etanercept have been shown to significantly increase the risk of HZ. Additionally, younger age and female sex may be risk factors.

SYSTEMATIC REVIEW REGISTRATION NUMBER

INPLASY202110027.

Association Between the Risk for Cardiovascular Events and Antiviral Treatment for Herpes Zoster

BACKGROUND

Cardiovascular risk increases following herpes zoster. We investigated whether treatment with antiviral agents, steroids, and common cardiovascular medications was associated with the risk of postherpetic cardiovascular events.

METHODS

This was a nationwide population-based, retrospective, cohort study using the National Health Insurance Service health claims data in Korea. We included patients with a first-ever diagnosis of herpes zoster in 2003-2014 and no prior cardiovascular event. The primary outcome was the occurrence of composites of myocardial infarction (International Statistical Classification of Diseases, Tenth Revision, code I21) and stroke (codes I60-I63) since the herpes zoster. We analyzed the exposure (intravenous or oral administration) to antiviral agents, steroids, antithrombotics, and statins within ±7 days from the index date of herpes zoster diagnosis. Follow-up was performed until occurrence of the primary outcome, death, or 31 December 2015, whichever came first.

RESULTS

Of 84 993 patients with herpes zoster, the proportions of patients who received the treatment with antiviral agents, steroids, antithrombotics, and statins were 90.5%, 48.0%, 9.1%, and 7.9%, respectively. During the mean (standard deviation) follow-up period of 5.4 (3.1) years, 1523 patients experienced the primary outcome. Multivariate Cox regression analysis demonstrated that treatment with antiviral agents (adjusted hazard ratio, 0.82; 95% confidence interval, .71-.95) and statins (0.71; .59-.85) were significantly associated with the lower risk of primary outcome. Use of antithrombotics and steroids were not associated with the risk.

CONCLUSIONS

After herpes zoster, treatment with antiviral agents was significantly associated with lower risk of cardiovascular events. We need more information on the cardiovascular protective role of herpes zoster treatments.

Retrospective Analysis of 170 Patients Followed up with Herpes Zoster and Postherpetic Neuralgia in Nothern Cyprus

Herpes zoster is viral infection that occurs with reactivation of the varicella-zoster virus (VZV). It is usually a painful but self-limited dermatomal rash with  cutaneous distribution. Although it's usually a painful, self-limiting rash, it can be much more serious; In addition, acute cases often lead to postherpetic neuralgia (PHN) and seriously impair quality of life. It is important to recognize those at risk of developing postherpetic neuralgia, early treatment and prevent complications. Objectives :Our aim is to determine the clinical features of our herpes zoster diseases and to review the treatments in patients with postherpetic neuralgia. Methods: A search for HZ and PHN was conducted in a general practice research database, comprising 2 general practices( dermatologist and physatrist) and representing 5600 people. We analyzed a retrospective 170 case series of pediatirc and adults addmited  to the dermatology and physical therapy and rehabilitation outpatient clinic between October 2018 and October 2020. Results: A total of 170 new cases had been diagnosed with HZ in the dermatology and physical therapy and rehabilitation clinics over 2 years . Female to male ratio was 2:1 and the age ranged from 5 years to 88 years. The thoracic dermatomes were the most commonly involved. The risk of developing PHN 1 month after the start of the zoster rash was 21 %. Independent risk indicators for the occurrence of PHN were age [55–74] years. Conclusion : The risk of developing PHN increases with age and with commorbitity. Preventive strategies such as vaccination should focus on patients with herpes zoster aged >55 years.

Burden of Herpes Zoster in Adult Patients with Underlying Conditions: Analysis of German Claims Data, 2007-2018

INTRODUCTION

Several chronic underlying conditions (UCs) are known to be risk factors for developing herpes zoster (HZ) and to increase the severity of HZ and its risk of recurrence. The aim of this study was to investigate the incidence and recurrence of HZ in adult patients with one or multiple UCs.

METHODS

A retrospective cohort study based on claims data representing 13% of the statutory health insurance population from 2007 to 2018 in Germany was performed. Patients aged ≥ 18 years were included when at least one of the following UCs was diagnosed: asthma, chronic heart failure, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), depression, diabetes mellitus type 1 or 2, and rheumatoid arthritis (RA). Exact matching was used to account for differences in the distribution of age and sex between the case and matched control cohorts. Multi-morbidity was considered in sensitivity analyses by analyzing patients with only one UC.

RESULTS

Patients with asthma, CHD, COPD, depression, and RA had, on average, a 30% increased risk of developing acute HZ compared to patients without any UC. RA was found to have the highest odds ratio among these conditions, varying from 1.37 to 1.57 for all age groups. Patients with depression also showed a high risk of developing HZ. Analysis of recurrence indicated that patients with at least one UC in the age groups 18-49 years and 50-59 years had the highest risk for a recurrent HZ. After experiencing a first recurrence, patients, regardless of age group, had a two- to threefold higher risk for a second recurrence.

CONCLUSION

This study of representative claims data shows a higher HZ incidence and recurrence frequency in patients with UCs. These results provide relevant information for national health care guidelines and disease management programs.

Should we prescribe anticonvulsants for acute herpes zoster neuralgia and to prevent postherpetic neuralgia?: A protocol for meta-analysis and benefit-risk assessment

BACKGROUND

Herpes zoster-associated pain [i.e., acute herpes zoster neuralgia (AHN) and postherpetic neuralgia (PHN)] has the potential to cause significant patients' burden and heath resource expenditure. PHN is refractory to the existing treatments, and the consensus is preventing the transition of AHN to PHN is better than treating PHN. Anticonvulsants (e.g., gabapentin, pregabalin) have been recommended as one of the first-line therapies for PHN. In practice, anticonvulsants have also decreased the severity and duration of AHN and reduced the incidence of PHN. Nevertheless, its clinical application to AHN is hampered by inadequate evidence for its efficacy and safety. We performed this protocol for a systematic review to explore the efficacy and safety of anticonvulsants for AHN. Besides, a benefit-risk assessment of anticonvulsants for AHN would be performed to estimate the extent to which these drugs could relieve symptoms and whether the benefits outweigh harms.

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) was used to prepare our protocol and the results will be reported according to the PRISMA. We will search the China National Knowledge Infrastructure (CNKI), Chinese VIP Information (VIP), Cochrane Library, Embase, and PubMed databases, from inception to August 2019. Furthermore, Clinicaltrials (http://www.clinicaltrials.com) and Chinese Clinical Trial Registry (http://www.chictr.org.cn/abouten.aspx) will also be searched for relevant studies. Selection of eligible articles and data extraction will be independently performed by reviewers. We will record the characteristic information, pain outcomes, incidence of PHN and adverse effects. Data synthesis and other statistical analyses will be conducted using Review Manager Software 5.3 and STATA13.0. Furthermore, risk of bias assessment, meta-regression and subgroup analyses, publication bias assessment, grading of evidence will be performed for included studies.

ETHICS AND DISSEMINATION

As this systematic review will be performed based on published data, no ethical approval is needed. The findings will be submitted in peer-reviewed journals for publication.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019133449.