Herpes zoster itch: preliminary epidemiologic data

The best-known complication of shingles (herpes zoster) is postherpetic neuralgia (PHN). PHN is commonly studied to investigate causes of and treatments for neuropathic pain. However, many patients with shingles experience neuropathic itch accompanying, or instead of, pain. Some report severe disabling postherpetic itch (PHI), and though it is rare, some patients injure themselves by scratching itchy skin that has lost protective sensation. To date, there is virtually no mention of PHI in the medical literature; neither epidemiologic, anatomic, physiologic, nor treatment studies. We analyzed 3 independent existing sets of data from 586 adults with shingles or PHN to glean epidemiologic information about pruritus during and after shingles. All data refer to itch localized to shingles-affected areas and initiated by shingles. They indicate that pruritus, usually mild or moderate, commonly accompanies both acute zoster and PHN. There was no significant difference in age between subjects with and without PHI. In one group, but not in another, there was an increased number of women with PHI. Subjects whose shingles affected the head, face, and neck were more likely to experience PHI than those whose shingles affected the torso. These findings indicate a need for research on zoster-associated itch, including prospective studies on frequency, impact, and treatment.

Intractable postherpetic itch and cutaneous deafferentation after facial shingles

Some patients develop chronic itch from neurological injuries, and shingles may be a common cause. Neuropathic itch can lead to self-injury from scratching desensate skin. A 39-year-old woman experienced severe postherpetic itch, but no postherpetic neuralgia, after ophthalmic zoster. Within 1 year, she had painlessly scratched through her frontal skull into her brain. Sensory testing and skin biopsies were performed on itchy and normal scalp to generate preliminary hypotheses about mechanisms of neuropathic itch. Quantitation of epidermal neurites in PGP9.5-immunolabeled skin biopsies demonstrated loss of 96% of epidermal innervation in the itchy area. Quantitative sensory testing indicated severe damage to most sensory modalities except itch. These data indicate that in this patient, severe postherpetic itch was associated with loss of peripheral sensory neurons. Possible mechanisms include electrical hyperactivity of hypo-afferented central itch-specific neurons, selective preservation of peripheral itch-fibers from neighboring unaffected dermatomes, and/or imbalance between excitation and inhibition of second-order sensory neurons.

Neuropathic itch

Chronic itch can be caused by dysfunctions of itch-sensing neurons that produce sensory hallucinations of pruritogenic stimuli. The cellular and molecular mechanisms are still unknown. All neurological disease categories have been implicated, and neurological causes should be considered for patients with otherwise-unexplained itch. The same neurological illnesses that cause neuropathic pain can also or instead cause itch. These include shingles (particularly of the head or neck), small-fiber polyneuropathies, radiculopathies (eg, notalgia paresthetica and brachioradial pruritis), and diverse lesions of the trigeminal nerve, root, and central tracts. Central nervous system lesions affecting sensory pathways, including strokes, multiple sclerosis, and cavernous hemangiomas, can cause central itch. Neuropathic itch is a potent trigger of reflex and volitional scratching although this provides only fleeting relief. Rare patients whose lesion causes sensory loss as well as neuropathic itch can scratch deeply enough to cause painless self-injury. The most common location is on the face (trigeminal trophic syndrome). Treating neuropathic itch is difficult; antihistamines, corticosteroids, and most pain medications are largely ineffective. Current treatment recommendations include local or systemic administration of inhibitors of neuronal excitability (especially local anesthetics) and barriers to reduce scratching.

Systematic cutaneous examination in hepatitis C virus infected patients

The purpose of this study was to evaluate the frequency of skin changes among 100 patients from the Hepatogastroenterology Department of the University Hospital, Strasbourg, France who were hepatitis C virus-positive (HCV) and HIV-negative. Their clinical data were compared to those of 50 HCV-, and HIV-negative patients from the same Department, who suffered from various liver diseases. Psoriasis, rosacea, seborrheic dermatitis, cherry angiomas, spider nevus and skin cancers were noted in similar proportions in the two groups. In 15% of HCV-positive patients vs. 4% of controls, chronic pruritus was noted (p < 0.05). In 9 HCV-positive patients, pruritus was not related to itching dermatosis, and only 2 of these patients had mild cholestasis. Four cases of lichen planus vs. 0 in the control group were recorded. The virological data of patients with pruritus or lichen planus were not different than those of the rest of the group. Our findings indicate that systematic skin check-up in HCV-positive patients is valuable.

Beyond zoster: sensory and immune changes in zoster-affected dermatomes: a review*

Neuroepidermal tropism of varicella-zoster virus accounts for cutaneous and nerve lesions following herpes zoster. Skin lesions heal in a few weeks and may or may not leave visible scars. Nerve lesions involve peripheral sensory fibres, sometimes causing permanent damage that results in partial denervation of the affected dermatome. The effects of the nerve injury involve the sensibility function, thus causing neuralgia, itch, allodynia, hypo- or anaesthesia, as well as the immune function that is related to neuropeptide release, thus altering immune control in the affected dermatome. The neuro-immune destabilization in the zoster-infected site paves the way for the onset of many and various immunity-related disorders along the affected dermatome.

Alterations in HIV expression in AIDS patients with psoriasis or pruritus treated with phototherapy

BACKGROUND

Ultraviolet light (UVL) upregulates HIV transcription in vitro and in transgenic mice. AIDS-associated psoriasis and pruritus respond to phototherapy.

OBJECTIVE

Our goal was to determine the effect of phototherapy on viral load and immunologic parameters in HIV-positive patients.

METHODS

T cell subsets, p24, plasma cytokines, serum or plasma HIV-RNA, dosage, and antivirals were assessed in HIV-positive patients and negative controls receiving 6 weeks of phototherapy with UVB and in untreated controls.

RESULTS

Phototherapy improved skin conditions without significantly affecting T cell numbers. Plasma p24 increased 2-fold (P = .055) and HIV-RNA levels 4-fold (P = .022) 6 weeks from baseline in patients who entered the trial before March 1995. Later patients who were mostly receiving combination antiviral therapy showed a 4-fold reduction in serum HIV-RNA (P = .012) at 2 weeks. The effect of UVB on viral load at 6 weeks was dependent on the baseline level (P = .006). IL-10 increased and was inversely related to HIV-RNA levels (P = .0267).

CONCLUSION

Phototherapy is associated with HIV load alterations, depending on patients' initial HIV-RNA, antiviral therapy, skin type, and UVL dosage.

Herpes simplex labialis after epidural or parenteral morphine: a randomized prospective trial in an Australian obstetric population

A prospective randomized controlled trial was conducted in women undergoing emergency and elective caesarean section to determine whether epidural morphine predisposes to postoperative herpes simplex labialis and whether the risk is increased or decreased by previous oral herpes or pruritus. Following cannulation of the epidural space, analgesia for labour and/or caesarean section was induced in two groups of similar age, parity, preoperative status and anaesthetic. According to tables of random numbers, 386 were allocated to receive parenteral morphine and 425 to receive epidural morphine. Postoperative herpes labialis was diagnosed by laboratory culture and microscopy. Patients who received epidural morphine were 11.5 times (95% CI 2.6-49.4) more likely than the parenteral morphine group to suffer herpes labialis. A past history of oral herpes increased the risk of herpes labialis by 8.6 times (95% CI 3.3-22.0). When the influence of past herpes infection and route of morphine were taken into account, no separate association between pruritus and herpes simplex labialis could be demonstrated.

Cutaneous markers of HIV infection

Despite the development of laboratory methods, dermatological symptoms are a basic index of the presence and physical course of HIV infection. HIV infection usually undergoes a long latent period, proceeds to a period of immunodeficiency-related symptoms, and ends in an advanced immunodeficiency state characterized by opportunistic infections and neoplasms. Occasionally, dermatological manifestations can be the first signs of asymptomatic disease, indices of advanced immunodeficiency, or symptoms of opportunistic infections or neoplasms. The variety of symptoms and signs for the skin during the course of HIV infection is a consequence of the progressing immunodeficiency and therefore indicates the underlying disorder. The use of these manifestations is a challenge for clinical praxis.

Dermatologic Manifestations of Chronic Hepatitis C Infection

Chronic hepatitis C virus (HCV) infection is associated with various extrahepatic manifestations, including dermatologic involvement mostly caused by immune complexes. Mixed cryoglobulinemia has a strong relationship with HCV with 95% of these patients being infected with HCV. Lichen planus is a disease of the squamous epithelium and may affect any part of the skin, with 4% to 24% of patients with lichen planus reported to have chronic HCV infection. Porphyria cutanea tarda is the most common form of porphyria, and it is thought that HCV interferes with iron stores, which can promote porphyria cutanea tarda. Finally, necrolytic acral erythema is a rare, psoriasis-like disease closely associated with HCV.

Intractable pruritus in HIV infection: immunologic characterization

BACKGROUND

Severe, intractable pruritus, often associated with erythematopapular skin lesions and hypereosinophilia, is a condition observed in some nonatopic, HIV-infected patients. We performed immunovirologic analyses of this condition.

METHODS

Immunologic (mitogen-stimulated production of cytokines, tumor necrosis factor-alpha [TNF-alpha], and soluble CD23; serum levels of soluble CD23, ICAM-1, TNF-alpha, IgG, IgE, and IgA) and virologic (HIV viral load) parameters were analyzed in six patients with therapy-resistant pruritus. Hypereosinophilia was present in all these patients. Results were compared to those of seven HIV-seropositive individuals similar to the first one in terms of CD4 counts and clinical staging, but without pruritus.

RESULTS

Hypereosinophilia; hyper-IgE and hyper-IgA; augmented interleukin (IL)-4, IL-5, and sCD23; and reduced interferon-gamma production by mitogen-stimulated peripheral blood mononuclear cells (PBMC) were detected when patients with pruritus were compared to HIV controls. HIV viral load was also augmented in patients in whom pruritus was present.

CONCLUSIONS

The results suggest that therapy-resistant, intractable pruritus accompanied by hypereosinophilia may be used to define a subset of HIV-seropositive individuals showing prototypic hyperactivation of humoral immunity, and in whom augmented HIV viral load is present.

A review of anatomical and immunological links between epidural morphine and herpes simplex labialis in obstetric patients

The anatomical basis for facial itch after epidural morphone is outlined. CNS nuclear events which reactivate latent herpes simplex and immune inhibition resulting in maternal mouth vesicles or neonatal infections are described. Morphine is hypothesized to affect these processes and facial itch is only a marker, not a trigger of this trigeminal opioid activity.

Cytokine expression patterns distinguish HIV associated skin diseases

AIDS is known to cause a shift of cytokines in the periphery. However, predominant cytokines in skin of patients with HIV-associated skin diseases have not been clearly defined. We hypothesized that there are distinct cytokine profiles that distinguish among the different clinical manifestations of AIDS-related skin diseases. To test this hypothesis, lesional and non-lesional skin was biopsied from 53 HIV+ patients with Kaposi's sarcoma (KS), psoriasis, and pruritus due to eosinophilic folliculitis, and from HIV negative controls with psoriasis or KS prior to therapy. Immunohistochemistry was performed with antibodies to tumor necrosis factor (TNF)-alpha, interleukin (IL)-10, interferon (IFN)-gamma, and interferon-inducible protein (IP)-10. HIV positive individuals included 10 with psoriasis, 14 with pruritus, and 15 with Kaposi's sarcoma. HIV negative controls included 12 with psoriasis and two with KS. Semi-quantitative analysis of cytokine staining was confirmed by optical density using a digital imaging system on four representative skin sections from each disease. Optical density analyses were conducted using ANOVA and t-tests. We found that epidermis overlying HIV+ Kaposi's sarcoma was hyperproliferative and was highest in IP-10, IFN-gamma, and IL-10 (P=0.0001). HIV+ pruritus was significantly highest in TNF-alpha (P=0.0001) staining. HIV+ psoriasis represented an intermediate state for all four cytokines. Normal skin adjacent to lesions showed the same relative patterns, with lower intensities. Skin diseases seen frequently in the setting of HIV and immunodeficiency have relatively distinct levels and patterns of cytokine expression that may reflect immune dysfunction, reactivity to HIV and to opportunistic infections.

Cutaneous manifestations in patients positive for anti-hepatitis C virus antibodies

Cutaneous diseases can indicate the presence of hepatitis C virus (HCV) infection. The aim of this study was to analyse the frequency of cutaneous findings in HCV infection and HCV RNA positive cases in Turkey. Fifty consecutive patients positive for anti-HCV antibodies,negative controls, and patients positive and negative for HCV RNA were examined for any cutaneous findings that could be associated with HCV infection. The risk of infected patients developing cutaneous finding was higher than for non-infected individuals. Only pruritus showed a statistically significant difference in separate assessment of cutaneous symptoms. There were no differences in cutaneous findings in HCV RNA positive and negative cases. The risk of developing a dermatological finding, especially pruritus, was increased in HCV infection.However, because the number of patients in this study was too low to allow statistical evaluation of the prevalence of dermatological symptoms and diseases, multicentre studies including large numbers of patients are needed.

The Emerging Zika Virus Threat: A Guide for Dermatologists

We provide a guide for dermatologists to follow if they encounter patients with a rash and clinical history suspicious of Zika virus infection, including diagnostic testing and management options. We also provide an illustrative case report of a patient from Brazil who was diagnosed with Zika virus infection after presenting with a generalized pruritic rash. One of the most prominent symptoms of Zika virus infection is a cutaneous eruption. As such, it is especially necessary for dermatologists to understand this virus so that they may appropriately recognize this entity as a diagnostic consideration in the clinic. The rash associated with Zika virus infection is most commonly an erythematous maculopapular eruption that presents after an initial 3-4 days of fever, headache, and arthralgia or myalgia. The rash typically lasts for an average of 6 days, and can spread to involve any part of the body, including the face, torso, extremities, palms, and soles.

Intractable pruritus in patients with hepatitis C virus

Intractable pruritus is one of the most common symptoms of chronic liver disease, especially experienced by patients with prolonged cholestasis. It can become the most distressing symptom in patients affected by chronic liver disease, causing a reduction in quality of life, interfering with daily activities, and leading to sleep deprivation or contributing to psychological disturbances up to suicide ideation. Therefore, pruritus that does not respond to medical therapy is an indication for liver transplantation. We treated nine patients with hepatitis C virus affected by intractable pruritus with the molecular adsorbent recirculating system. In each patient, liver function, renal function, and hemodynamic variables were evaluated before and after the treatment. Before undergoing the treatment each patient underwent abdominal ultrasound or computed tomography scan to exclude organic causes for pruritus. We observed a decrease in total bilirubin, creatinine, and bile acids together with a significant improvement in Visual Analog Scale for staging of pruritus in all the patients. Due to the small number of patients the results were not significant.

Association of Allergic Symptoms with Dengue Infection and Severity: A Systematic Review and Meta-analysis

The relationship between the severity of dengue infection and allergy is still obscure. We conducted an electronic search across 12 databases for relevant articles reporting allergic symptoms, dengue infection, and dengue classification. These studies were categorized according to dengue severity and allergy symptoms, and a meta-analysis was performed by pooling the studies in each category. Among the included 57 articles, pruritus was the most common allergic sign followed by non-specified allergy and asthma (28.6%, 13%, and 6.5%, respectively). Despite the reported significant association of dengue with pruritus and total IgE level (P < 0.05), in comparison with non-dengue cases and healthy controls, there was no association between the different severe dengue group with pruritus, skin allergy, food allergy or asthma. However, removing the largest study revealed a significant association between asthma with dengue hemorrhagic fever (DHF) rather than dengue fever (DF). In comparison with DF, DHF was associated with IgE positivity. Furthermore, specific-IgE level was higher in secondary DF rather than primary DF. There was a possible association between allergy symptoms and dengue severity progression. Further studies are needed to clarify this association.

Barmah Forest viral exanthems

A series of five patients presented with eruptions beginning on the face. In each case the facial changes were characterized by urticated erythema with minimal epidermal change. The patients also demonstrated more widespread vesiculopapular, macular or purpuric eruptions. At presentation most patients were asymptomatic; however, several subsequently developed constitutional symptoms. Each of these patients was reactive for Barmah Forest virus immunoglobulin (Ig)M, and on repeat testing four were reactive for Barmah Forest virus IgG.