POST-HERPETIC

NEURALGIA
AND ITS
MANAGEMENT

DR. AYESHA ASLAM

 Post herpetic Neuralgia is defined as pain

along cutaneous nerves persisting for
more than 30 days after the onset of
Herpes Zoster rash.

INCIDENCE

 incidence of post herpetic neuralgia

increases with age
uncommon in patients younger than 60
years

10
9
8

8.8

7
6
5
4
3
2

2.0

1
0

01 MONTH

03 MONTHS

PATIENTS < 60 YRS

01 YEAR

45
40

40.8

35
30
25
INCIDENCE

20
15

13.0

10

7.8

5
0

01 MONTH

03 MONTHS

01 YEAR

PATIENTS > 60 YRS

PATHOPHYSIOLOGY OF PHN

Varicella

neurochemical

FREQUENCY

 In US each year approximately 1,000,000

individuals develop herpes zoster.
Of those individuals approximately 20%,
or 200,000 individuals, develop
postherpetic neuralgia.

PRE-DISPOSING
FACTORS

 Susceptibility to HZ - > in caucasians

Old & Debilitated
Immuno-compromised patients
Acute neuritis in the early phase of
disease

CLINICAL
PRESENTATION

SYMPTOMS:
Pain
- ranges from mild discomfort to severe
burning, aching or gnawing
- constant
Allodynia
Headaches
Fatigue
Sleep disturbances

PAIN INTENSITY IN PHN

SIGNS:
Cutaneous scarring of HZ lesions in the
affected areas
Altered sensations over the affected
dermatome
- Lowered threshold for cold, warmth
& vibration
- Poor two-point discrimination
Muscle weakness, tremor or paralysis -if
the nerves involved also control muscle
movement

SCARRING AND PIGMENTARY CHANGES IN

THE AFFECTED DERMATOME

DIAGNOSIS

 History
Examination - dermatomal pattern of
distribution and the appearance of the herpes
zoster rash

In cases where the diagnosis

is in doubt:
PCR Techniques - detect the varicella DNA in
fluid taken from the vesicles

Direct Immunofluorescent Antigen

Staining Test
VZ specific IgM
Virus cultures

PREVENTION

 No treatment has been shown to prevent

postherpetic neuralgia completely.
However, some treatments may shorten
the duration or lessen the severity of
symptoms.
Prevention could be:
Primary
Secondary

PRIMARY PREVENTION

 The only really effective way of preventing

post herpetic neuralgia from developing is
to protect yourself from shingles and/or
chicken pox with the
chickenpox (varicella) vaccine
the shingles (varicella-zoster)
vaccine

CHICKENPOX VACCINE
Varivax vaccine
routinely given to children aged 12 -18
months to prevent chickenpox
also recommended for adults and older
children who have never had chickenpox
does not provide 100% immunity but
reduces the risk of complications and
severity of the disease.

VACCINE FOR CHICKENPOX

SHINGLES VACCINE
Zostavax vaccine
helps protect adults over 60 who have had
chickenpox.
Recommended
that people over 60 have this vaccine
, regardless of whether or not they h
ave had shingles before
.
The vaccine is preventative, and is not
used to treat people who are infected.

VACCINE FOR SHINGLES

SECONDARY
PREVENTION

 Aggressively treating shingles with

antiviral agents such as Acyclovir within
02 days of the rash can reduce both the
risk of developing subsequent neuralgia or
the length and severity if it does.

TREATMENT OF PHN

DIRECT PAIN INHIBITION

ANALGESICS
o Topical
o Systemic

PAIN MODIFICATION THERAPY

ANTI-DEPRESSANTS
ANTI-CONVULSANTS
STEROIDS

OTHERS
TENS
PERIPHERAL NERVE STIMULATION
SPINAL CORD STIMULATION
SURGICAL INTERVENTION

1. ANALGESICS

TOPICAL AGENTS
Lidocaine Skin Patches
small, bandage-like patches that contain
lidocaine
must be applied directly to painful skin to
deliver relief for 04-12 hours.
avoid contact with mucus membranes
e.g. eyes, nose and mouth.

 TOPICAL CAPSAICIN
an extract of hot chilli peppers
depletes substance P from nerve
terminals & desensitizes them
0.025 % cream (Zostrix) applied four times
daily

 EMLA
A eutectic mixture of lidocaine and
prilocaine
Reported to be beneficial in pain relief

 Aspirin
mixed into an appropriate solvent such as
diethyl ether may reduce pain

SYSTEMIC AGENTS
OPIOIDS
- Oxycodone (Oxycontin) 10 mg twice
daily
- a small risk of dependency exists

PAIN MODIFICATION
THERAPY

1. TRICYCLIC
ANTI- DEPRESSANTS
Affect key brain chemicals, such as
serotonin and norepinephrine
Influence how the body interprets pain
Dosages tend to be lower
Examples include
Amitriptyline 10-75mg /d

Desipramine (Norpramin) 25mg/d

Nortriptyline (Pamelor) 10-25mg/d
Duloxetine (Cymbalta)

 AMITRIPTYLINE
Single most effective drug
Anticholinergic and cardiovascular sideeffects must be considered
Given at bedtime to improve tolerance
and prevent daytime somnolence

2. ANTI-CONVULSANTS
effective in calming down nerve impulses
stabilize abnormal electrical activity in the
nervous system caused by injured nerves
Effective in patients who experience
stabbing pain in addition to the burning
sensation

 Examples include
Gabapentin (Neurontin) 100-300mg/d
Pregabalin (Lyrica) 50-75mg/d
Lamotrigine (Lamictal)
Carbamazepine (Tegratol)
Phenytoin (Dilantin)

3. STEROIDS
METHYLPREDNISOLONE is injected into
the area around the spinal cord i.e
intrathecally
Effective for patients with chronic pain
Administered only after the shingles
pustular skin rash has completely
disappeared
Patients unresponsive to oral/topical
therapy should be considered

TRANSCUTANEOUS ELECTRIC
NERVE STIMULATION

 Electrodes are placed over the areas

where pain occurs
Small electrical impulses are emitted and
provide pain relief
The patient turns the TENS device on and
off as required
TENS stimulates ENDORPHIN releasethe body's natural painkillers

PERIPHERAL NERVE
STIMULATION

 The devices are surgically implanted

under the skin, along the course of
peripheral nerves.
As soon as the electrodes are in place,
they are switched on to administer a weak
electrical current to the nerve.
The patient will have a tingling sensation
in the area.

SPINAL CORD
STIMULATION

 The spinal cord stimulator is inserted

through the skin into the epidural space
over the spinal cord
Works in the same way as peripheral
nerve stimulator

SURGICAL TREATMENT

 For patients who do not respond to

medical therapy
Outcome of surgical procedures in case of
PHN is far from certain in regard to pain
management
Blockade of affected nerves
Neurectomy
Surgery at the level of dorsal root
ganglion

PROGNOSIS

 The natural history of PHN involves slow

resolution of the pain syndrome
In those patients who develop PHN, most
will respond to agents such as the
Tricyclic Antidepressants
A subgroup of patients may develop
severe, long-lasting pain that does not
respond to medical therapy