Postherpetic Neuralgia Treatment & Management
- Author: W Alvin McElveen, MD; Chief Editor: Robert A Egan, MD more...
The financial implications for treatment of postherpetic neuralgia are becoming more important as the population ages. Dworkin et al examined annualized costs for persistent pain in patients with herpes zoster. Annualized costs were $4917 for commercially insured patients, $2696 for Medicare patients and $9310 for Medicaid patients.
A clinical trial has shown that a live-attenuated varicella-zoster virus vaccine is effective against herpes zoster (HZ) and postherpetic neuralgia (PHN). Brisson estimates that for 65-year-olds, the number needed to vaccinate (HZ vaccine efficacy=63%, PHN vaccine efficacy=67%, no waning) to prevent a case of HZ, a case of PHN, an HZ death, a life-year lost, and a quality-adjusted life-year lost is estimated to be 11 (90% Crl: 10-13), 43 (90% Crl: 33-53), 23,319 (90% Crl: 15,312-33,139), 3762 (90% Crl: 1650-4629), and 165 (90% Crl: 105-197), respectively. Results of this study show that the main benefit of HZ vaccination is prevention of morbidity caused by pain.
In March 2011, the Food and Drug Administration (FDA) lowered the approved age for use of Zostavax to 50-59 years. Zostavax was already approved for use in individuals aged 60 years or older. Annually, in the United States, shingles affects approximately 200,000 healthy people aged 50-59 years. Approval was based on a multicenter study, the Zostavax Efficacy and Safety Trial (ZEST). The trial was conducted in the United States and 4 other countries in 22,439 people aged 50-59 years. Participants were randomized in a 1:1 ratio to receive either Zostavax or placebo. Participants were monitored for at least 1 year to see if shingles developed. Compared with placebo, Zostavax significantly reduced the risk of developing zoster by approximately 70%.
Chen et al found vitamin C plasma concentrations are lower in 38 patients with postherpetic neuralgia compared with 39 healthy volunteers (P < .001). In this study, restoration of vitamin C concentrations decreased spontaneous pain (but not brush-evoked pain) by 3.1 on a numeric pain scale in the postherpetic neuralgia group compared with placebo treatment (P < 0.001). The authors concluded that vitamin C status is a component in postherpetic neuralgia and is a component involved in spontaneous pain relief.
In a small study by Kanai et al, lidocaine 4% ophthalmic drops were administered to 24 patients with ophthalmic postherpetic neuralgia in a crossover manner. A significant reduction in eye and forehead pain was observed in patients who received the lidocaine ophthalmic drops. Analgesic onset was noted via a visual analog scale within 15 minutes after administration and persisted for a median of 36 hours (range, 8-96 h).
See the list below:
Dorsal root entry zone (DREZ) lesions have been used.
- Efficacy - Improvement rate is 20% in long-term studies.
- Complications - Gait disturbances are experienced by 12% of treated patients.
Hicks LD, Cook-Norris RH, Mendoza N, Madkan V, Arora A, Tyring SK. Family history as a risk factor for herpes zoster: a case-control study. Arch Dermatol. 2008 May. 144(5):603-8. [Medline].
Helgason S, Petursson G, Gudmundsson S, Sigurdsson JA. Prevalence of postherpetic neuralgia after a first episode of herpes zoster: prospective study with long term follow up. BMJ. 2000 Sep 30. 321(7264):794-6. [Medline].
Delaney A, Colvin LA, Fallon MT, et al. Postherpetic neuralgia: from preclinical models to the clinic. Neurotherapeutics. 2009 Oct. 6(4):630-7. [Medline].
Spiegel R, Miron D, Lumelsky D, Horovitz Y. Severe Meningoencephalitis Due to Late Reactivation of Varicella-Zoster Virus in an Immunocompetent Child. J Child Neurol. 2009 Jun 3. [Medline].
Haanpaa M, Dastidar P, Weinberg A, et al. CSF and MRI findings in patients with acute herpes zoster. Neurology. 1998 Nov. 51(5):1405-11. [Medline].
Dworkin RH, White R, O'Connor AB, Hawkins K. Health care expenditure burden of persisting herpes zoster pain. Pain Med. 2008 Apr. 9(3):348-53. [Medline].
Brisson M. Estimating the number needed to vaccinate to prevent herpes zoster-related disease, health care resource use and mortality. Can J Public Health. 2008 Sep-Oct. 99(5):383-6. [Medline].
Schmader K, Levin M, Gnann J, McNeil S, Vesikari T, et al. Efficacy, immunogenicity, safety, and tolerability of zoster vaccine (ZV) in subjects 50 to 59 years of age (Poster/Abstract). Infectious Diseases Society of America. The 48th Annual Meeting of the Infectious Diseases Society of America. 10-21-2010. Vancouver, British Columbia, Canada:Ref Type: Abstract: 3363.
Chen JY, Chang CY, Feng PH, Chu CC, So EC, Hu ML. Plasma vitamin C is lower in postherpetic neuralgia patients and administration of vitamin C reduces spontaneous pain but not brush-evoked pain. Clin J Pain. 2009 Sep. 25(7):562-9. [Medline].
Kanai A, Okamoto T, Suzuki K, Niki Y, Okamoto H. Lidocaine eye drops attenuate pain associated with ophthalmic postherpetic neuralgia. Anesth Analg. 2010 May 1. 110(5):1457-60. [Medline].
Benzon HT, Chekka K, Darnule A, Chung B, Wille O, Malik K. Evidence-based case report: the prevention and management of postherpetic neuralgia with emphasis on interventional procedures. Reg Anesth Pain Med. 2009 Sep-Oct. 34(5):514-21. [Medline].
Gilron I, Bailey JM, Tu D, Holden RR, Jackson AC, Houlden RL. Nortriptyline and gabapentin, alone and in combination for neuropathic pain: a double-blind, randomised controlled crossover trial. Lancet. 2009 Oct 10. 374(9697):1252-61. [Medline].
Irving GA, Backonja M, Rauck R, Webster LR, Tobias JK, Vanhove GF. NGX-4010, a Capsaicin 8% Dermal Patch, Administered Alone or in Combination With Systemic Neuropathic Pain Medications, Reduces Pain in Patients With Postherpetic Neuralgia. Clin J Pain. 2011 Jul 12. [Medline].
Baron R, Saguer M. Mechanical allodynia in postherpetic neuralgia: evidence for central mechanisms depending on nociceptive C-fiber degeneration. Neurology. 1995 Dec. 45(12 Suppl 8):S63-5. [Medline].
Bowsher D. The management of postherpetic neuralgia. Postgrad Med J. 1997 Oct. 73(864):623-9. [Medline].
Choo PW, Galil K, Donahue JG, et al. Risk factors for postherpetic neuralgia. Arch Intern Med. 1997 Jun 9. 157(11):1217-24. [Medline].
Freynhagen R, Strojek K, Griesing T, et al. Efficacy of pregabalin in neuropathic pain evaluated in a 12-week, randomised, double-blind, multicentre, placebo-controlled trial of flexible- and fixed-dose regimens. Pain. 2005 Jun. 115(3):254-63. [Medline].
Johnson RW. Herpes zoster and postherpetic neuralgia. Optimal treatment. Drugs Aging. 1997 Feb. 10(2):80-94. [Medline].
Kotani N, Kushikata T, Hashimoto H, et al. Intrathecal methylprednisolone for intractable postherpetic neuralgia. N Engl J Med. 2000 Nov 23. 343(21):1514-9. [Medline].
Merritt HH. A Textbook of Neurology. 1979. 90.
Nurmikko T. Clinical features and pathophysiologic mechanisms of postherpetic neuralgia. Neurology. 1995 Dec. 45(12 Suppl 8):S54-5. [Medline].
Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005 Jun 2. 352(22):2271-84. [Medline].
Rath SA, Braun V, Soliman N, et al. Results of DREZ coagulations for pain related to plexus lesions, spinal cord injuries and postherpetic neuralgia. Acta Neurochir (Wien). 1996. 138(4):364-9. [Medline].
Rowbotham M, Harden N, Stacey B, et al. Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial. JAMA. 1998 Dec 2. 280(21):1837-42. [Medline].
Rowbotham MC, Davies PS, Fields HL. Topical lidocaine gel relieves postherpetic neuralgia. Ann Neurol. 1995 Feb. 37(2):246-53. [Medline].
Tyring S, Barbarash RA, Nahlik JE, et al. Famciclovir for the treatment of acute herpes zoster: effects on acute disease and postherpetic neuralgia. A randomized, double-blind, placebo-controlled trial. Collaborative Famciclovir Herpes Zoster Study Group. Ann Intern Med. 1995 Jul 15. 123(2):89-96. [Medline].
Watson CP. Postherpetic neuralgia. Neurol Clin. 1989 May. 7(2):231-48. [Medline].
Watson CP, Vernich L, Chipman M, Reed K. Nortriptyline versus amitriptyline in postherpetic neuralgia: a randomized trial. Neurology. 1998 Oct. 51(4):1166-71. [Medline].
Watson CPN, Gershon AA. Herpes Zoster and Post Herpetic Neuralgia. Vol 11. 2001:90-93, 108-109.
Whitley RJ, Shukla S, Crooks RJ. The identification of risk factors associated with persistent pain following herpes zoster. J Infect Dis. 1998 Nov. 178 Suppl 1:S71-5. [Medline].