Mdica - a Journal of Clinical Medicine

MAEDICA a Journal of Clinical Medicine

2015; 10(3): 276-279

C ASE REPORT

Treatment of Postherpetic
Neuralgia Using Narrow Band
Ultraviolet B Radiation (UVB)
Piotr BRZEZINSKIa; Ewelina CYWINSKAa,b; Anca CHIRIACc,d
a
Department of Dermatology, 6th Military Support Unit, Ustka, Poland
b
Trychoderm Private Clinic, Slupsk, Poland
c
Department of Dermato-Physiology, Apollonia University, Iasi, Romania
d
Institute of Macromolecular Chemistry, Apollonia University, Petru Poni Nicolina
Medical Center, Iasi, Romania

ABSTRACT
Postherpetic neuralgia (PHN) is a common complication of herpes zoster, frequently unresponsive to
most available treatment. The disease is especially difficult to manage in elderly people and has a great
impact on the quality of life of patients.
Narrow band ultraviolet B radiation may play a role in the prevention and treatment of PHN.
Present paper describes a case of a 59 year-old female patient, diagnosed with ophthalmic herpes zoster
and postherpetic neuralgia, with positive results using narrow UVB.

Keywords: herpes zoster; postherpetic neuralgia; narrow UVB; complications

INTRODUCTION vates. At a certain moment, when the host

resistance drops below a critical level, VZV re-

H
erpes zoster (HZ) or shingles is a
neurocutaneous disease caused
by reactivation of latent varicel-
la-zoster virus (VZV) (1). VZV is a
deoxyribonucleic acid (DNA) vi-
rus that belongs to the human alpha-herpes vi-
ruses, together with herpes simplex viruses
(HSV) type I and type II.VZV is the causal agent
of chickenpox (varicella) especially in children
and herpes zoster in elderly and immunocom-
promised individuals.
The prevalence of herpes zoster infection is
reported to be between 0.30.5% (2).
After the initial phase of varicella, VZV re-
mains dormant in the sensory ganglia for a la-
tency period (months-years) before it reacti-
activates and virus replication starts. VZV
spreads down the sensory nerve causing neuri-
tis and extends around the sensory nerve into
the skin inducing dermatomal zoster skin le-
sions.
Frequently reported complications include:
bacterial infections and consequent scars for
skin, conjunctivitis, episcleritis/scleritis, uveitis,
keratitis, iridocyclitis for eyes, and encephalitis,
meningitis, granulomatous arteritis, segmental
paresis affect the central nervous system (3).
Zoster pain is classified in acute pain and
postherpetic neuralgia (PHN). The actual defi-
nition of PHN is: pain that persists for more
than three months after the onset of herpes
zoster (4).

Address for correspondence:

Piotr Brzezinski, Department of Dermatology, 6th Military Support Unit, Ledowo 1N, 76-270 Ustka, Poland.
E-mail: brzezoo77@yahoo.com

Article received on the 23rd of February 2015. Article accepted on the 15th of June 2015.

276 Maedica A Journal of Clinical Medicine, Volume 10 No.3 2015

 TREATMENT OF POSTHERPETIC NEURALGIA USING NARROW BAND ULTRAVIOLET B RADIATION (UVB)
PHN has been reported in 9-45% of all cas-
es of herpes zoster (HZ) and even higher (50
60%) among elderly or immunosuppressed pa-
tients.
For a long time solar ultraviolet (UV) radia-
tion (heliotherapy) and phototherapy have
been used in order to attempt treating several
skin diseases. Nowadays, phototherapy is a
valuable therapeutic method used in nume-
rous skin diseases (5), including HZ (6).
CASE REPORT
A 56-year-old female patient was addressed
to the Department of Dermatology for ery-
thematous plaques distributed over left upper
hemifacial area. Three months prior to consul-
tation, the patient was diagnosed with ophthal-
mic zoster and treated with acyclovir (800 mg
five times /day for 10 days).
The dermatological examination revealed
erythematous skin lesions accompanied by in-
tense pain on the left upper hemifacial area.
The patient admitted an increasing intensity of
pain during the weeks that followed the herpes
zoster.
A diagnosis of postherpetic neuralgia (PHN)
was established.
A special therapeutic approach to the pa-
tient was recommended: nbUVB (narrow band
UVB-311-Dermalight) - 3 sessions per week,
up to a total of 20 sessions, performed at the
Trychoderm Clinic in Slupsk, Poland under
strictly medical surveillance.
The starting dose was 0.21 J/cm2, then the
dose was increased by one increment every
session to a point of 20 sessions, in the absence
of any adverse reactions reported by the pa-
tient, such as persistent erythema, burn or itch-
ing.
The patient was graded with regard to her
pain severity using a 4-point Verbal Rating
Scale (VRS):
0=no pain,
1=mild pain that does not interfere with
daily activities
2=moderate pain that interferes with daily
activities, but does not cause sleeplessness
3=severe pain that causes sleeplessness
4=very severe, unbearable and extremely
incapacitating pain.
The patient was subjectively evaluated re-
garding the pain index and degree of improve-
ment once weekly. VRS was scored before the
treatment and at the end of nbUVB sessions.
VRS was also used for close follow-up of the
patient at 2 months follow-up.
Before treatment the score was 4.
At the end of third session the score was 3,
after 7 sessions 2, after 14 sessions 1 and at the
end of cure: 0.
The score remained 0 one month after the
therapy ceased and remained at that level for
two month.
DISCUSSION
A bout 20-25% of cases of HZ develop PHN
as a secondary complication, beside bacte-
rial superinfection (7).
Postherpetic neuralgia (PHN) is considered
to be a chronic neuropathic pain that involves
aberrant somatosensory processing in the pe-
ripheral and/or central nervous system (1).
PHN can also be defined as the pain lasting
for more than 1-3 months or even years after
the onset of herpes zoster (8). One report
claims that 15 % of HZ cases have PHN 2 years
after the zoster rash (9).
Known risk factors for PHN include: ad-
vanced age, female gender, chronic debilitating
diseases, immunocompromised condition, and
a severe acute phase of HZ (10).
Patients with HZ have a lower incidence of
PHN in the age group below 60 compared to
the ones over 60 (11).
PHN has been recently found in higher inci-
dence in patients after traumatic brain injury
(12).
HZ vaccination has been reported with a
lower risk of PHN in women, not in men ac-
FIGURE 1. Erythematous lesions on the forehead in a 56 year old
female patient during treatment with UVB narrow.
Maedica A Journal of Clinical Medicine, Volume 10 No.3 2015 277
TREATMENT OF POSTHERPETIC NEURALGIA USING NARROW BAND ULTRAVIOLET B RADIATION (UVB)
cordingly to a very recent study, but further in-
vestigations are needed (13).
The exact pathogenesis of zoster pain still
remains debatable, but it is admitted to be
mostly immunologically mediated (1), especial-
ly VZV-specific cell-mediated immunity (14).
PHN is described by the patients as bur-
ning, itching, and even stabbing, localized to
the dermatomal area with preceding herpes
zoster skin lesions. Pain can be associated with
sleep disturbance, depressive symptoms; can
be paroxysmal or continuous, with variable de-
grees and can affect deeply daily social activi-
ties.
Treatment of PHN is difficult because the
majority of cases are unresponsive to most
available treatment modalities.
Oral treatment for PHN can include:
tricyclic antidepressants (acting by block-
ing sodium, calcium and NMDA recep-
tors and by inhibiting serotonin and nor-
epinephrine reuptake) (15).
opioids analgesics( acting as mu-recep-
tor agonists) (16).
and anticonvulsants: gabapentin and
pregabalin (blocking calcium channels in
neurons) (17).
NSAIDs, oral steroids.
Topical agents have been used, during the
last decades, for PHN: local anesthetics (topical
lidocaine by blocking voltage-gated sodium
channels)(18), topical capsaicin (affecting the
TRPV1 receptor and producing depletion of
substance P which is a neurotransmitter) (19),
diclofenac, clonidine, gabapentin, opioids (20),
topical amitriptyline (21), topical or intranasal
ketamine (22), local injections of botulinum
toxin type A (23), all with unimpressive effects
especially on long term evolution.
Ultraviolet B (UVB) phototherapy was used
for the first time in two studies done by Jalali et
al. in 2008 and respectively by Nabarawy in
2011 as an attempt to treat PHN (1,8).
Nabarawy enrolled in the study 17 patients
with distressing PHN; patients were evaluated
using the Verbal Rating Scale (VRS). The pa-
tients received nbUVB sessions, three times a
week, for a total of 15 sessions or until the pain
disappeared. As results more than 50% im-
provement was achieved in 6 (35.29%) and 8
(47.06%) patients, at the end of therapy and
after 3 months follow up, respectively. An im-
provement less that 50% was achieved in 11
(64.71%) and 9 (52.94%) patients, at the end of
therapy (1).
278 Maedica A Journal of Clinical Medicine, Volume 10 No.3 2015
Jalali et al. described the evolution of 12 pa-
tients older than 40 years, with PHN treated
with nbUVB phototherapy. The group received
oral acyclovir (800 mg five times a day for 10
days) plus nbUVB to the affected dermatomes,
during the first 7 days of rash, starting with 20
mJ/cm2 then gradually increasing the dose by
10 mJ/cm2 each session to a maximum dose of
100 mJ/cm2. Sessions were repeated three
times a week until pain relief or to a maximum
of 15 sessions. A percentage of 58.33% and
83.33% of treated patients were completely
pain free at at one and three months follow-up,
respectively (8).
UVB radiation reaches the epidermis and
the upper dermis, while UVA radiation pene-
trates more deeply into the dermis, with effects
on blood vessels, dendritic cells, fibroblasts,
mast cells, granulocytes. Narrowband UVB
(nbUVB) causes local and systemic immuno-
suppressive effects by activating keratinocytes,
circulating and cutaneous T lymphocytes,
monocytes, Langerhans cell, mast cells and fi-
broblasts (6).
The immunomodulatory effects of UVB ra-
diation can explain, at least in part, the benefi-
cial effects observed in HZ (1,8).
Many hypotheses have been launched in
order to explain the mechanisms induced by
UVB in PHN. UVB phototherapy can suppress
the inflammatory response during the acute
phase of HZ and thus preventing or decreasing
the intensity of PHN, but applied 3 months af-
ter the onset of HZ the beneficial effect is low
(8).
UVB phototherapy can also have a positive
effect by decreasing the neuronal damage in
HZ, contributing also to improve PHN.
UVB can interact with Langerhanss cells
that are believed to be involved in inducing
neuritis and play a role in immune response
(24).
UVB also suppresses antigen presentation of
LCs, stimulates keratinocytes and mast cells to
secrete immunosuppressive cytokines such as
IL-10, TNF-, IL-4, PG-E2, -MSH or CGRP
(25), modifies the T-cell response to persistent
VZV particles in nerve fibers (26), induces a
shift from a Th-1 immune response to a Th-2
response (1), reduce the cutaneous nerve den-
sity in the epidermis and superficial dermis
(27).
In present case nbUVB proved to be effec-
tive in PHN, when it was performed three
 TREATMENT OF POSTHERPETIC NEURALGIA USING NARROW BAND ULTRAVIOLET B RADIATION (UVB)

months after HZ. The absence of pain persisted
2 months after the last nbUVB session.
No side effects were reported neither du-
ring therapy nor after the treatment, all sessions
were well tolerated.
CONCLUSION
cial in such a debilitating complication of her-
pes zoster such as PHN, especially in elderly. It
is a non-invasive, easy to perform, not very ex-
pensive, with minimal side effects valuable
method to be aware of.
Further studies are needed to validate the
indication of nUVB in PHN.

P romising results have been achieved using

nbUVB in postherpetic neuralgia, but more
studies are needed to conclude its real benefi-
Conflict of interests: none declared.
Financial support: none declared.

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