Zosterneuralgia B02.8

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

postherpetic neuralgia; Postherpetic neuralgia; Postzosteric neuralgia; Postzosterneualgy; Post-Zoster Neuralgia; Zosterschmerz

Definition
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After herpes zoster and often beyond the period of the actual skin changes, persistent, often unbearable, segmental pain with a typical, shooting character, also known as post-zosteric or post-herpetic neuralgia (PHN).

Post-zosteric neuralgia is a neuropathic pain syndrome that persists for more than 4 weeks and only occurs 3 months (>90 days) after the typical skin changes, after a pain-free interval. The post-zosteric neuralgia can significantly affect the quality of life of the affected person. About 10-30% of all >50 year olds develop this zoster complication. The pain is perceived differently as:

  • constantly persistent
  • recurrent
  • lightning-like shooting in (as with light current contacts)
  • allodynically occurring at the slightest touch.

Etiopathogenesis
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Various research results indicate that reorganisation processes in the posterior horn and peripheral nerve damage due to demyelination of afferent sensory fibres and small-fibre degeneration are the causes of the development of PZN (Fields HL et al. 1998).

Manifestation
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Occurring in 9-14% of all zoster patients and in 50% of patients with zoster over 60 years of age. In women and in patients with zoster ophthalmicus, post-zosteric neuralgia (PZN) appears to be more common. Deficiency of the immune system does not seem to be a risk for PZN.

Histology
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Inflammatory necrosis of the spinal ganglion, the motor and sensory parts of the spinal cord, accompanied by neuritis and myelitis

Therapy
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Causal therapy of herpes zoster!

Light to moderate pain:

  • Paracetamol (e.g. Ben-u-ron Tbl./Supp.) 4-6 times/day 500-1000 mg p.o.

Severe pain, postzoster neuralgia:

  • Carbamazepine (e.g. Tegretal Tbl.) initial 2 times/day 100-200 mg p.o., increase every 5 days by 200 mg, at dose > 800 mg/day, distributed over 4 ED; maintenance dose 800-1600 mg/day. Cave! Control of active levels of carbamazepine in serum (normal value: 4-12 mg/l), BB, transaminases, creatinine every 5 days. In case of overdose extrapyramidal motor disorders.
  • Alternatively: Gabapentin (= anticonvulsant; e.g. Gabapentin® STADA) initially once/day 300 mg, increase to 300 mg p.o. 3 times/day; further dose increase ,if necessary, with intact kidney function (control of the kidney parameters!), by 300 mg/day up to a maximum dose of 3600 mg/day in 3 ED.
  • Alternatively: Valaciclovir in combination with Gabapentin (Valciclovir 1mal/day 1000mg; Gabapentin initial 300mg 1mal/day increase up to 3600mg/day. In a larger study on 133 patients, significant advantages regarding pain problems could be achieved compared to historical collectives (Lapolla et al. 2011).

Pain of ischaemia:

  • Pain initially on exertion, later possibly also at rest due to insufficient blood circulation with cramp-like pain on exertion; rapid improvement on relief (e.g. standing still).

Burning pain at rest:

  • Use of non-opioids such as tramadol (e.g. Tramal®) 2-3 times/day 100-300 mg p.o. or antidepressants such as amitriptyline (e.g. Sarotene) in ascending doses of 10 mg/day (week 1), 25 mg/day (week 2), 50 mg/day (week 3), then further according to effect and side effects.

Acute postzoster neuralgia or duration of the disease > 3 months:

  • Amitriptyline (e.g. Sarotene) or Nortriptyline (e.g. Nortrilen®) in ascending dosage with 10 mg/day in the evening (week 1), 3 times/day 10 mg or 25 mg/day in the evening (week 2), 3 times/day 25 mg or 50 mg/day in the evening (week 3 and 4), from week 5 on dosage according to effect and side effects.
  • Alternatively: Doxepin (e.g. Aponal®) 3 times/day 10-50 mg, Imipramine (e.g. Tofranil®) 3 times/day 10-50 mg. The additional administration of 40-80 mg prednisolone (p.o or i.v.) has a beneficial effect on acute pain, but not on the development of chronic pain.

For neuralgiform pain:

  • Carbamazepine (e.g. Tegretal®) in increasing dosage, starting at 200 mg 1-2 times/day, increasing by 200 mg every 5 days. Over 800 mg distributed on 3-4 ED, maintenance dose 800-1600 mg/day, target serum level 5-10 g/l.
  • Alternatively: Baclofen (e.g. Lioresal®) 3 times/day 5-10 mg, increase every 3 days by 5-10 mg, maintenance dose 60 mg/day distributed in 3-6 ED.
  • If the effect is insufficient: Ibuprofen retard 3 times/day 800 mg. Alternatively: Metamizole (e.g. Novalgin®) 4000 mg/day, acetylsalicylic acid 4000 mg/day, paracetamol 4000 mg/day. Ultima ratio: Morphine test and corresponding setting.

Sympathetic nervous system blockades:

  • Ganglion cervicale superius (infestation of the 1st-2nd trigeminal branch): 0.03 mg buprenorphine on 2 ml 0.9% NaCl solution; 10 blockades every 2nd day.
  • Stellate blockade (infestation of the 3rd trigeminal branch Th4): 5-10 ml of a local anaesthetic such as 0.5% bupivacaine or 0.03 mg buprenorphine per 5 ml of 0.9% NaCl solution; 10 blockades every 2nd day.
  • Epidural catheter (infestation Th5-L5): 5-10 ml 0.25% bupivacaine, max. 2 weeks.
  • Alternativen: Plexus catheter, paravertebral blockade, border strand blockade.

Accompanying therapy: acupuncture, cryo-analgesia, pain management training, hypnosis.

External therapy
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Accompanying:

0.075% capsaicin ointment (e.g. Dolenon®, Capsamol®). 5x daily for 2 weeks, afterwards as required.

5% Lidocaine patch (12h treatment break)

Progression/forecast
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Average duration 6 months, at 5-10% up to 10 years. Cooperation with the anaesthetists.

Prophylaxis
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With the adjuvanted inactivated vaccine Shingrix, a highly effective therapeutic agent has been available since 2018 that offers age-independent and long-lasting protection against zoster and zoster neuralgia. The drug has been used in a Phase III study program in 38,000 patients worldwide. The approval refers to patients >50 years. It should be used as early as possible in the zoster infection. The intramuscular injections are administered twice at intervals of 2 (ggfl. 6) months.

Note(s)
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An additional high-dose administration of glucocorticoids shortens the phase of acute zoster pain. With regard to post-zosteric neuralgia, steroidal therapy does not seem to have a positive effect.

Literature
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  1. Avijgan M et al(2017) Postherpetic Neuralgia: Practical Experiences Return to Traditional ChineseMedicine
    .J Acupunct Meridian Stud 10:157-164.
  2. Chen CJ et al (2003) Acupuncture, electrostimulation, and reflex therapy in dermatology. Dermatol Ther 16: 87-92
  3. Dworkin RH et al (2003) Treatment and prevention of postherpetic neuralgia. Clin Infect Dis 36: 877-882
  4. Fields HL et al (1998) Postherpetic neuralgia: irritable nociceptors and deafferentation. Neurobiol Dis 5:209-227.
  5. Forbes HJ et al (2016) A systematic review and meta-analysis of risk factors for postherpetic neuralgia. Pain 157:30-54.
  6. Gilron I et al (2005) Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med 352: 1324-1334
  7. Harden RN (2005) Chronic neuropathic pain. Mechanisms, diagnosis, and treatment. Neurologist 11: 111-122
  8. Lapolla W et al (2011) Incidence of postherpetic neuralgia after combination treatment with gabapentinand
    valacyclovir in patients with acute herpes zoster: open-label study. Arch Dermatol 147:901-907.
  9. Singh D et al (2003) The use of gabapentin for the treatment of postherpetic neuralgia. Clin Ther 25: 852-859
  10. Weinberg JM et al (2003) Cutaneous infections in the elderly: diagnosis and management. Dermatol Ther 16: 195-205
  11. Zenz M (1995) Pocketbook of pain therapy. Scientific publishing company mbH Stuttgart

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020