Acute Herpes Zoster

&
Post herpetic
Neuralgia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

Herpes zoster
Herpes zoster is an infectious disease
that is caused by the varicella-zoster
virus
It is postulated that during the course
of primary infection with VZV, the
virus migrates to the dorsal root or
cranial ganglia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

Herpes zoster
In some individuals the virus may
reactivate and travel along peripheral
or cranial sensory pathways to the
nerve endings, producing the pain and
skin lesions characteristic of shingles
The reason for reactivation ?
decrease in cell-mediated immunity
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

Risk factors
Suffering from malignancies (particularly
lymphoma)

Receiving immunosuppressive therapy

(chemotherapy, steroids, radiation)

Generally debilitated by chronic

diseases
Patients older than 60 years

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

SIGNS AND SYMPTOMS

Herpetic pain:
5-7 day before of skin lesions
May be accompanied by flu-like symptoms
Progresses from a dull, aching sensation to
unilateral,
Segmental, band-like dysesthesias and
hyperpathia
Burning pain , hyperesthesia, allodynia
Zoster sine herpete

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

SIGNS AND SYMPTOMS

From a mild self-limited problem to a
debilitating, constantly burning pain
that is exacerbated by light touch,
movement, anxiety,and/or
temperature change
Can lead to suicide

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

SIGNS AND SYMPTOMS

Thoracic dermatomes
Cervical region
Trigeminal nerve
lumbosacral region
Ramsay Hunt syndrome

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

52%
20%
17%
II %

SIGNS AND SYMPTOMS

Skin lesions
Crops of macular lesions
Papules
Vesicles
Crusting
Crusts fall away (Scabs)
Pink scars
Hypopigmented and atrophic scars

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Differential Diagnosis
Appendicitis
Contact dermatitis
Intervertebral disc
Erysipelas
disease
Folliculitis
Myocardial infarction
Incontinentia pigmenti
Pleurisy
Jellyfish sting
Renal stone
Lichen striatus
Trigeminal neuralgia
Pemphigus
Cholecystitis
Photoallergic reaction
Glaucoma
Phytophotodermatitis
Bells palsy
Rhus dermatitis
Brachioradial pruritus
Urticaria
Bullous impetigo
Zosteriform herpes
Bullous pemphigoid
Zosteriform metastasis
Candidiasis
Cellulitis
Dr Mehran Rezvani pain fellowship
Caterpillar dermatitis
anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

COMPLICATIONS

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Relief of acute pain and symptoms
Prevention of complications, including
postherpetic neuralgia
Earlier treatment
less likely postherpetic
neuralgia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

TREATMENT
Careful initial evaluation, including a
thorough history and physical
examination, is indicated to rule out
occult malignancy or systemic
disease

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Sympathetic neural blockade appears
to be the treatment of choice to
relieve the symptoms of acute
herpes zoster as well as to prevent
the occurrence of postherpetic
neuralgia
Noordenbos "fiber dissociation"

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Herpes zoster in trigeminal nerve & geniculate,
cervical, and high thoracic regions:
stellate ganglionblockade with
LA daily basis
Herpes zoster thoracic, lumbar, and sacral
regions:
epidural neural blockade with
LA
daily basis
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

TREATMENT
If the pain is not as severe, NSAIDs or
acetaminophen may be all that is
needed
In acute eruption oral narcotics may
be
administered in the short term,
especially with (NSAIDs)
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

TREATMENT
Narcotic analgesics may be useful in
relieving the aching pain
Antidepressants will help :
Alleviate the significant sleep disturbance
Ameliorate the neurotic component of the pain
May exert a mood-elevating
May cause urinary retention and constipation

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Anticonvulsants
May be of value as an adjunct to sympathetic
neural blockade
They may be particularly useful in persistent
paresthetic or dysesthetic pain

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Anxiety may be treated
Hydroxyzine
Behavioral interventions
(e.g., monitored relaxation training and hypnosis)

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Antiviral agents:
Acyclovir , valacyclovir, famcyclovir
and perhaps interferon have been
shown to shorten the course of acute
herpes zoster

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Corticosteroids
In systemic ? (the risk of dissemination?)
Local infiltration of affected skin areas with
corticosteroid with or without local
anesthetic
may be of value as an adjunct to
sympathetic neural blockade

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Local application of ice packs
Application of heat
Transcutaneous electrical nerve
stimulation
Vibration
Spinal cord stimulation

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Topical application
Aluminum sulfat
Zinc oxide ointment
Topical lidocaine patches for PHN
Topical capsaicin for PHN

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Postherpetic
Neuralgia
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

Pain persisting after the rash has

healed (usually 1 month (or2, 3, or
even 6months after the disease onset) is
termed PHN
Zoster-associated pain:
all pain beginning before, at onset, and after
the rash

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Negative and positive symptoms

Allodynia is a characteristic feature of
PHN that occurs in the affected skin
dermatomes
Dysesthesias in the affected dermatome
spontaneous pain
Areas of sensory loss that lack responses
to thermal, tactile, pinprick, or vibratory
stimuli
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

Risk factors for PHN

Older patients
Vulnerable nerve syndrome
(e.g., diabetes)
Herpes zoster of the trigeminal nerve and
then midthoracic lead to more lead to PHN
Time of antiviral thrapy (72h)

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

PHN

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Differential Diagnosis
Thoracic nerve roots include

Thoracic radiculopathy
Peripheral neuropathy
Intrathoracic and intra-abdominal
pathology

Ophtalmic trigeminal nerve

Diseases of the eye, ear, nose, and

throat Intracranial pathology
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

TREATMENT
The anticonvulsant gabapentin
represents a first-line
Carbamazepine
Phenytoin
Antidepressants may also be useful

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Sympathetic neural blockade with local
anesthetics and steroids via either
epidural nerve block or blockade of
the sympathetic nerves may be next
step ?
Some texts: peripheral nerve,
epidural, or sympathetic anesthetic
blocks do not appear to be useful
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

TREATMENT
Neurodestructive procedures have a
very low success rate
Opioid analgesics have a limited role
Application of ice packs
Application of heat
Transcutaneous electrical nerve
stimulation
Vibration
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

FDA APPROVED
gabapentin
Pregabalin
Topical lidocaine patch5%
Capsaicin cream

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
Topical local anesthetics, such as
EMLA cream
Subcutaneous lidocaine infiltration
Intrathecal methylprednisolone
Implanted spinal catheters and
pumps
Dorsal root entry zone lesion
Behavioral therapy
Dr Mehran Rezvani pain fellowship
anesthesiologist & acupuncturist

TREATMENT
In one controlled trial (Kotani et al.
2000),
repeated intrathecal administration
of methylprednisolone acetate
resulted in sustained pain relief in
90% of PHN
The treatment was well tolerated

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

TREATMENT
If the pain is severe, and all other
methods fail, immediate pain relief
may be obtained in hospitalized
patients with a short course of highdose chlorprothixene (50mg every 6
hours for 5 days)

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

 Neurolytic blocks may be considered

in patients with PHN when other
blocks have not given the patient
significantrelief
Significant pain relief has been
obtained in patientswith PHN using
acupuncture

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Surgery and Neurosurgery

the last resort for the treatment of
severe intractable postherpetic
neuralgia:
Cordotomy
Dorsal column stimulators
Deep brain stimulators

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist

Dr Mehran Rezvani pain fellowship

anesthesiologist & acupuncturist