DefinitionThis section has been translated automatically.
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
- lightning-like shooting in (as with light current contacts)
- allodynically occurring at the slightest touch.
EtiopathogenesisThis section has been translated automatically.
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).
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ManifestationThis section has been translated automatically.
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.
HistologyThis section has been translated automatically.
TherapyThis section has been translated automatically.
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 therapyThis section has been translated automatically.
0.075% capsaicin ointment (e.g. Dolenon®, Capsamol®). 5x daily for 2 weeks, afterwards as required.
5% Lidocaine patch (12h treatment break)
Progression/forecastThis section has been translated automatically.
Average duration 6 months, at 5-10% up to 10 years. Cooperation with the anaesthetists.
ProphylaxisThis section has been translated automatically.
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)This section has been translated automatically.
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.
LiteratureThis section has been translated automatically.
- Avijgan M et al(2017) Postherpetic Neuralgia: Practical Experiences Return to Traditional ChineseMedicine
.J Acupunct Meridian Stud 10:157-164.
- Chen CJ et al (2003) Acupuncture, electrostimulation, and reflex therapy in dermatology. Dermatol Ther 16: 87-92
- Dworkin RH et al (2003) Treatment and prevention of postherpetic neuralgia. Clin Infect Dis 36: 877-882
- Fields HL et al (1998) Postherpetic neuralgia: irritable nociceptors and deafferentation. Neurobiol Dis 5:209-227.
- Forbes HJ et al (2016) A systematic review and meta-analysis of risk factors for postherpetic neuralgia. Pain 157:30-54.
- Gilron I et al (2005) Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med 352: 1324-1334
- Harden RN (2005) Chronic neuropathic pain. Mechanisms, diagnosis, and treatment. Neurologist 11: 111-122
- 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.
- Singh D et al (2003) The use of gabapentin for the treatment of postherpetic neuralgia. Clin Ther 25: 852-859
- Weinberg JM et al (2003) Cutaneous infections in the elderly: diagnosis and management. Dermatol Ther 16: 195-205
- Zenz M (1995) Pocketbook of pain therapy. Scientific publishing company mbH Stuttgart
Incoming links (9)Amantadine; Baclofen; Cantharide patch; Capsici fructus acer; Postzosteric neuralgia; Ranunculus bulbosus; Shingrix; Zoster ophthalmicus; Zosterschmerz;
Outgoing links (13)Acetylsalicylic acid; Allodynia; Amitriptyline; Baclofen; Bupivacaine; Buprenorphine; Carbamazepine; Doxepin; Ibuprofen; Imipramine; ... Show all
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