Herpes Zoster and Post herpetic Neuralgia:

Evidenced based guidelines for the Gerontological Nurse Practioner.

Tracy Ann Ramos BS , R N. April 6, 2006

Presentation Objectives.
Identify the risk factors and clinical manifestations of herpes zoster and potential complications in the older adult. Briefly review the epidemiology, Pathophysiology and diagnoses of herpes zoster and its complications. Recognize the burden of illness of herpes zoster through discussion of recent research findings and clinical data. Articulate evidence based therapeutic solutions, (Nonpharmacological, pharmacological and complimentary therapies) to the management of post-herpetic neuralgia there by improving the quality of life of the older adult. Discuss the implications of the GNP role in the management and future research of post-hepatic neuralgia.

Role and responsibilities of the GNP in the treatment of Herpes zoster and PHN.
Assisting the older adult to function at his or hers highest level. Assisting the older adult in minimizing health risks. Providing information, education and resources to older adults. Recognizing and addressing the frequently atypical response of older adults to disease and its treatments.

Scope and Standards of Gerontological Nursing (2002)

 Assessment, treatment and evaluation methodology based on evidenced based practice. Collaboration with the older adult, caregiver and all members of the healthcare team to provide comprehensive care. Provide guidance and care to the older adult that respects human dignity and the uniqueness of the individual. Considers factors related to safety ,effectiveness and cost in planning and delivering patient care.
Scope and Standards of Gerontological Nursing (2002)

Role and responsibilities of the GNP in the treatment of Herpes Zoster and PHN.

Definitions
Herpes Zoster:
Acute, localized infection of the Varicella-Zoster virus, which causes a painful blistering, pruritic rash.

Post-Herpetic Neuralgia:

Pain that persists for more than 1 month after the onset of Herpes zoster.

U.S Library of medicine 2006, Journal of Family practice(2003)

Historical Perspective
The Varicella-Zoster Virus is estimated to have been around 70 million years. Initially named by Hippocrates; herpes=to creep, Zoster = girdle (Greek) Shingles = belt, (Latin). Not until 1940 was the etiology of the virus established. VZV was finally isolated in 1952 by a Harvard Microbiologist. Finally sequenced in 1986.
Archives of Neurology ( 2004)

Question ?
In view of the Varicella vaccine introduced in 1995 for children, should we see more or less Herpes Zoster in the future ?

Epidemiology/ Etiology
Estimated 1 million cases in the U.S each year. Incidence increases with age and is expected to rise in the future due to reduced exposure to Varicella. The childhood Varicella vaccine may ultimately reduce the incidence of Herpes Zoster. Rarely seen < 50 years of age. 30% of previously immune persons > 60yrs have no detectable antibodies. VZV is a DNA virus, it is a neurocutaneous viral infection and a member of the herpes group. Recurrence of HZ is rare, unless immune-compromised, may be mistaken for herpes simplex.

Epidemiology/ Etiology
Following primary infection of the virus (Varicella chicken pox), it lies dormant until reactivated in later life. (Herpes Zoster-shingles) The virus lies dormant in the sensory nerve ganglia, dorsal root and cranial nerve ganglia. Reactivation of the virus is linked to a reduction of cell mediated immunity. (Age, immuno-compromised) Generally involves the skin of a single dermatome 15-35% of patients with Herpes Zoster will develop PHN African Americans are 1/4th as likely to develop Herpes Zoster
Postgraduate medicine (2005),Journal of pain(2005) .

Management guidelines for NPs working with older adults.(FADavis,2004)

Pathophysiology of Herpes Zoster

Reactivation can occur in the presence of stress, surgery, or injury. Following reactivation the virus travels at a possible rate of 1.7-10mm per hour. Estimated time for the virus to leave the ganglion and reach the peripheral nerve and the development of cutaneous vesicles is 48-96 hours. Hemorrhagic inflammation is characterized at the cellular level. Fibrosis is noted at the dorsal root ganglion, nerve root and peripheral nerve upon resolution of the acute stage.
The journal of Urology (2003)

Risk Factors for PHN

Replicated risk factors.
Older age Greater acute pain Severity of rash History of a prodrome.

Less well replicated risk factors.

Female gender Greater sensory abnormalities in the affected dermatome Polyneuropathy,brainstem and cervical cord abnormalities. Psychosocial variables
Lancet(2006) Journal of pain(2005)

Clinical Manifestations of Herpes zoster.

Prodrome symptoms may include chills, fever, malaise, G.I. disturbance and parasthesia or neuralgia along the affected dermatome. Red papules usually appear along the affected dermatome within 3 days.( usually last for <day) The eruption of vesicles closely follows the maculopapular rash. Vesicles are fluid filled and can transmit the virus, usually dry up in an average of 7 days. Scarring may occur at the site.
Mahan&Buttarro 2006, Merck manual of geriatrics (2000)

Clinical Manifestations of Herpes zoster.

Distribution: 50-60% Thoracic, 10-20%Trigeminal, 10-20%Cervical, 5-10% Lumbar, and <5% Sacral. 99% of all cases are unilateral and do not cross the midline unless there is > one dermatome affected or dissemination has occurred. (immune-compromised) Neuropathic pain may precede the onset of the rash or develop simultaneously . (Acute herpetic neuralgia) Without complications HZ typically lasts 2-4 weeks.
NLM (2006) Mahan & Buttaro 2006, Merck manual of geriatrics (2000)

Herpes vesicles

Ophthalmic Herpes zoster

Hutchinson sign

Ramsey Hunt syndrome

Question ?
What would you say the burden of illness is on the elderly given the clinical manifestations ?

Burden of illness
A cross sectional survey performed on 84 patients with PHN in 6 European countries.- Results:

Developed sleep disorder. Anxiety Depression Decreased walking ability (depending on dermatome) Withdrawal from relationships / activities. Reduction in the general enjoyment of life.
Age and aging, Oxford University,U.K (2006)

Question ?
What could be the differential diagnoses given these symptoms ?

Differential Diagnoses of Herpes Zoster

Herniated disc. MI Acute abdomen Musculoskeletal disorder. Pleurisy Migraine headache / Temporal artritis, Trigeminal neuralgia.

Polymyalgia rheumatica
Merck Manual of Geriatrics (2000)/postgrad medicine (2005)

Complications of Herpes Zoster

Bacterial infection of the skin.-requires ABT Corneal scarring /vision loss/conjunctivitisimmediate referral if eyes are involved. Encephalitis Guillain- Barre Syndrome. Urinary retention. Bells Palsy ( Zoster sine herpetic ) Cochlear vesicular involvement (Ramsey hunt syndrome)

Loss of taste

Merck Manual of Geriatrics(2000)BMj 2004

Clinical Presentation of PHN

Pain that persists for more than a month following the onset of Herpes Zoster. Pain may last months or in a few cases over a year. Pain is described as lacinating, burning, shooting, stabbing, paroxysmal or electrical. Allodynia occurs.( pain in reaction to a non- noxious stimulai,light touch, clothing). Pain can be debilitating and interfere with daily functioning . Pain through out the day Pain has 2 components : 1) Central , 2) Peripheral.
JAMA (2005), Pain (2006)

Question?
What questions would you ask in the History/R.O.S, in relation to Herpes Zoster/PHN ?

Patient history/ROS
PMH : Chicken pox, recent contacts, recent surgeries,current/ ongoing therapies, recent illness. Comorbidities. Social/History : Stress, lifestyle habits, support system/caregivers. Current state of health : Pain, (Old CART).? Dermatome,. Ask questions pertaining to rash. ? Allodynia (sensitive to fine touch), ? Hyperalgesia (abnormally low sensitivity to pain), ? Dysethesia (pins and needles, worms) . Ask questions pertinent to particular dermatome involved. Activities of daily living/quality of life. Rule out differential diagnoses. Journal of pain(2004)
Anesthesia &Analgesia (2003)

Question ?
What parts of the physical exam will you perform ?

Physical Examination
General survey. Skin inspection. Inspection of the rash if present. Location of dermatome, (exam system above and below) Neurological assessment of the affected dermatome. (vibration sense) Test for allodynia using cotton wool balls and sharp object. Adapt you assessment to the cognitively impaired person

Diagnostic Criteria
Diagnoses of Herpes Zoster / PHN is primarily clinical presentation: (May be all or some of the
following)

History of chicken pox in younger years Presence of prodromal symptoms Possible eruption of Maculopapular / vesicular rash. Neuropathic pain that follows the dermatomal path. Possible presence of either or all : Allodynia , Hyperalgesia, Dysethesia. Positive PCR
CDC guidelines 2005,Merck Manual 2000

Laboratory Tests
Tests are rarely indicated to confirm diagnosis. o Viral culture of vesicles. (takes several days) o Tzank test of skin lesions. (Dermatologist) o Direct immunoflurescence o Polymerase chain reaction (PCR). Gold standard. Baseline labs may be indicated o Rule out differential dx o CBC, BMP, ESR

NLM (2004)

Treatment Targets for Herpes Zoster / PHN

Should limit the severity and duration. Should be directed towards prevention of complications. Accelerate healing process. Facilitate the persons maximum daily function Avoid all unnecessary side effects of medications.
NEJM (2005)

Treatment plan
1) Promote healing ,reduce inflammation and pruritis of the
rash Domboro solution-OTC- most effective. Calamine lotion-OTC Oatmeal soak-OTC 2) Reduce viral shedding/DNA replication of the virus Acyclovir-less costly, equal outcome to others, more studies performed. 5xs a day dosing can be problem Famvir.-more costly but less dosing Valtrex-most expensive, less dosing required.
JAMA 2005, Semla et al 2006,BMJ 2003

Pain treatment plan

N.B: Start low and go Slow in the Elderly
3) Treatment of Acute herpetic neuralgia -Central pain
Tylenol -reg Tylenol X-tra strength Tramadol HCL (use cautiously) 4) Treatment of acute herpetic neuralgia--Peripheral pain. Lidocaine 5% topical-studies show most effective Capsaicin topical cream ( if allergy to lidocaine )
AJN 2003 Semla et al (2006)

Pain treatment plan

5) Treatment of post- herpetic neuralgia.
Garbapentin
Opioids-(used with extreme caution) Opioids-LTC where highly supervised. Community dwelling would recommend pain clinic referral. Neurology consult / pain clinic is indicated if adequate pain relief is not established

JAMA 2005, Semla et al 2006

Domboro Solution
Aluminum Sulfate and calcium acetate
Dosage/treatment OTC topical skin product. 1:40 dilution/1 packet in 16 ozs of water Soak affected area 15-20 mins,2-4 times day Effects inflammation,pruritis, drying of vesicles Side effects/considerations local signs may indicate allergic response to solution. Avoid contact with eyes.
Semla et al(2006)

Acetaminophen / Tylenol
Dosage/treatment OTC Analgesia 650mgs PO/PR Q4-6hrs,1000mg PO Q6-8hrs. Reduce TX renal function CrCL : 10-50ml/min =Q6hrs <10 ml/min= Q8 Effects/indications Mild-moderate pain Safest/preferred first line therapy for acute herpetic neuralgia in the elderly
VZV foundation guidelines

Acetaminophen / Tylenol
Side effects/considerations Rash (rare) Prolonged usage may cause hepatic,anemia,renal impairment Increases/decreases effects of certain drugs. (see Semla et al ) Avoid alcohol (liver) Reevaluate effect.
Semla et al (2006)BJM 2004

Lidocaine patch 5%
Dosage/treatment 10cms-14cms-700mgs of lidocaine 5%. 12hrs on 12hrs off. 3 patches can be worn same time Safety has been established for longer duration Effects/indications Topical anesthetic preferred in the first line treatment of acute/PHN Treatment of peripheral component of pain Side effects/considerations Mild transient skin reactions Do not use in patients with allergy to lidocaine. Do not place over active lesions/broken skin
AJN (2003),Semla et al (2006)

Capsaicin/Zostrix cream
Dosage/treatment
Topical analgesia with mod-poor efficacy Apply to affected area 3-4 times a day

Effects/indications
After repeated application capsaicin depletes substance P the main chemomediator of pain impulse

Side effects/considerations Transient burning Erythema Should not use on broken or irritated skin
Semla et al (2006),BJM (2004)

Acyclovir / Zovirax
Dosage/treatment
Anti viral agent Normal - 800mgs p.o 5xday for 7-10days. ADJUST FOR RENAL CLEARANCE Most effective when started within 72 hours of disease onset.

Effects/indications
Reduces viral shedding / DNA replication Reduces the intensity and duration of symptoms.

Side effects/considerations
Lightheadedness, headache,D&V, ABD pain. Use cautiously in renal impairment/nephrotoxic drugs.
NLM 2005, Semla et al 2006

Garbapentin / Neurontin
Dosage/treatment Anticonvulsant used in Neuropathic pain. 300mg p.o on day 1, 300mg p.o Bid day 2, 300mg p.o Tid on day 3,Titrate further as necessary. Doses >1800mg do not generally show greater relief. ADJUST RENAL DOSE Effects/indications FDA approved for Neuropathic pain and it is recommended as first line therapy for treatment of PHN. Side effects/considerations Somnolence, dizziness. D&V, mild edema - (rare) Patients should not use machinery until experience with drug.
National guideline clearing house (2005),Semla et al (2006),Archives of Neurology(2003) Cochrane data base (2006)

Tramadol
Dosage/treatment Non narcotic analgesia 50-100mg p.o Q 4 hours, NTE 300mg daily ADJUST FOR RENAL DOSE Effects/indications Use if Tylenol is ineffective
Use cautiously in the elderly Relief of moderate to severe pain

Side effects/considerations Constipation (consider stool softener) Somnolence, vertigo, nausea, This drug can be habit forming.
Pain(2003) Semla et al (2006)

Question ?
What Patient education will you perform?

Patient Education
Follow complete treatment plan Potential complications When to seek further medical intervention/RTC. Natural fiber clothing Prevent infection Prevent contact with imunocompromised people, pregnant women and people who have not had chicken pox until vesicles dry up.
BJM (2005)

Question ?
What patient referrals might you make?

Referrals
Ophthalmology- Ophthalmic herpes. Neurology/pain center-unrelieved pain Urology- urinary complications

Additional Notes.
Tricyclic antidepressants have been indicated in recent research as successful in the TX PHN , however due to the strong anticholinergic effect they should not be used as first line treatment. Would recommend referral to a pain clinic before using these drugs. Epidural steroids have a modest effect on PHN lasting approx 1 month. ( pain clinics usually advocate this if all other methods have been tried) NSAIDS have been successfully used in PHN, however they have the potential to cause gastric bleeding and are hepatotoxic.Would not use as first line TX.

Complimentary therapy
Very few studies were found on complimentary therapies for PHN/Neuropathic pain of this nature. Case study in Contemporary hypnosis (2004) 65 year old man with PHN for 18 months, felt his pain had taken over his life. No psychological problems, happily married. Stated the only time he was pain free was while riding a horse Agreed to try hypnosis and was taught to self hypnotize. Was successful in performing mini trance whenever he felt the pain emerge.

"Hope for the Future"

Shingles prevention study
National institute of allergy and infectious diseases / Merck & C.O)

(A joint effort of the V A and

38,546 adults > 60yrs enrolled in the study over a 3 year period. At 22 sites. Randomized double blind placebo controlled trial of a live attenuated VZV. 957 confirmed cases of HZ ( 315 in the vaccine group,642 in the placebo) 107 cases of PHN ( 27 in the vaccine group,80 in placebo group) Herpes zoster vaccine reduced the burden of illness by 61%
NEJM (2005)

Question ?
What future research might be indicated?

Future Research
Gender / race specific studies in PHN. Exploration of why pain intensifies towards the end of the day. The role of Complimentary therapies: Effect of Hypnosis, relaxation techniques, therapeutic touch, and Biofeedback have been studied on pain but not in relation to PHN. Reduction of emotional stress on the effect of PHN Staff knowledge in LTC on HZ/PHN and level/duration of pain of the patient. Community dwelling Vs facility dwelling on pain related to PHN Does socioeconomic status have a bearing on PHN

Implications for the GNP

To continuously review literature/increase knowledge for an improved treatment regime for Herpes Zoster/PHN. Careful assessment , R/O differential DX especially when only prodromal symptoms are present. Be mindful of cost versus benefits of treatment regime. (Side effects to medications, cost of treatment, cost of inadequate treatment). Commitment to explore all safe and new treatment options, in particular complimentary therapy. Promote organizational commitment to maintain pain as a number one priority and promote quality of life of the elderly. To maintain membership in professional organizations. ( another way to remain current and be a successful patient advocate)