Herpes Zoster

and Post herpetic Neuralgia

dr. Semuel A. Wagiu, SpS

Siang Klinik RSUD dr. M. Haulussy Ambon, 13 Pebruari 2010

 Brief

VARICELLA ZOSTER VIRUS

VZV is a DNA virus
belongs to the Herpes Virus Family

Causes two clinically distinct forms

of disease.
Chicken-pox (Varicella)
Primary infection

usually in childhood

Herpes Zoster (shingles)

secondary manifestation of
an earlier infection
later in life
 VARICELLA-CHICKENPOX
benign and self limiting illness.
Incubation period is 14-16 d
Skin lesions appear by day 14 in crops of
vesicles, pustules and crusted papules
on face, trunk, and extremities
spread by respiratory droplets or direct
contact with skin lesions.
highly contagious: 48 h prior to onset of
rash until skin lesions have fully crusted.
New lesion formation stops within 4 d
most lesions have fully crusted by day 6

Immunosupresed host:
susceptible to disseminated varicella
severe morbidity and higher Mt rates
Typically, the lesions of varicella
(7-14%)
are in different stages of
development
 VARICELLA-TREATMENT
Symptomatic :
Antihistamines, Acetaminophen ,
prevent scratching
Acyclovir :
reduces duration and severity of sy
within first 24 h of rash onset
recommended in healthy adults,
and immunocompromised
not recommended routinely in
otherwise healthy children.
After 25-72 h
no effect on the course of illness
IV-Acyclovir
for immunocompromised host
Primary infection with VZV even > 24 h of symptom onset
causes chicken pox
VARICELLA VACCINE

Recommended for all children 12-15 months

A two-dose schedule may be warranted in Canada in the future
Children who are nonimmune in whom vaccine is not
contraindicated should be offered postexposure vaccination
preferably within 96 h (four days).
Nonimmune children at risk for serious disease who are not
candidates for vaccine should be offered VZIG as soon as possible
and within 96 h of exposure
A child with mild illness should be allowed to return to school or
daycare as soon as he or she is well enough to participate
normally in all activities, regardless of the state of the rash.
 PATHOPHYSIOLOGY OF HZ
Following primary infection,
the virus
lies dormant in the sensory
nerve ganglia, dorsal root,
and cranial nerve ganglia,
until reactivated in later in
life causing Herpes Zoster.
Reactivation
occur in the presence of
stress, surgery, or injury.
linked to an age-related
diminished cell-mediated
immunity, therefore HZ
develops mainly in elderly
The virus travels at a possible rate of 1.7-10
mm per hour., reaches the skin in ~48-96 people and
hours. immunocompromised.
HERPES ZOSTER-CLINICAL PRESENTATION

Presents with rash and acute

neuritis.
The rash starts as small
papules which quickly evolve
into vesicles grouped on an
erythematous base.
Rash is painful, unilateral
and usually occurs in a
restricted dermatomal
distribution

Rash of HZ has been described as

"dew drops on a rose petal."
HERPES ZOSTER-CLINICAL PRESENTATION
Contagious for those who
have not had varicella or
have not received the
varicella vaccine
Lesions crust in 7-10 days
and are no more
infectious.
Without complications HZ
typically lasts 2-4 weeks.
DIAGNOSIS OF HERPES ZOSTER

Clinical: dermatomal
distribution of rash
PCR-most sensitive and
specific
Viral culture -low sensitivity
Direct immunofluorescent
antigen staining- test
(when PCR not available)
Tzank test
COMPLICATIONS OF HERPES
ZOSTER
Postherpetic neuralgia
Bacterial infection of skin
lesions
Ocular complication:
(conjunctivitis corneal scarring,
vision loss)
Encephalitis
Bells Palsy (Zoster sine herpetic)
Cochlear vesicular involvement
(Ramsey hunt syndrome)
Loss of taste
POSTHERPETIC NEURALGIA

Pain along cutaneus

nerves of involved
dermatome persisting
> 30 d after the
lesions have healed
Incidence of PHN
increases with age and is
uncommon in pt < 60 yo

AFP 2005

Helgason, S. et al. BMJ 2000;321:794

 Skema definisi nyeri pada Herpes Zoster

Onset Ruam Ruam Sembuh Nyeri Sembuh

Nyeri fase akut Neuralgia pasca herpes

> 1bln

NYERI ZOSTER
POSTHERPETIC NEURALGIA

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
stimuli, light touch, clothing).
Pain through out the day
Pain can be debilitating and
interfere with daily functioning

JAMA (2005), Pain (2006)

Risk factors for development of PHN:
Advancing age
Site of HZ involvement
Lower risk - Jaw, neck, sacral, and lumbar
Moderate risk - Thoracic
Highest risk - Trigeminal (especially ophthalmic
division), brachial plexus
Severe prodromal pain (with HZ)
Severe rash
OPHTHALMIC HERPES ZOSTER

Affects the ophthalmic branch of

the trigeminal nerve
Causes severe and lasting pain,
particularly among elderly pt.
Can be complicated by various
eye disorders in about 50 % of
all the pt if not treated
Might result in blindness if not
diagnosed and treated
adequately
OPHTHALMIC HERPES ZOSTER
HERPES ZOSTER OPHTHALMICUS

Ophthalmologist referral
recommended for emergency
assessment & treatment

Antiviral drugs
at first sign of infection
recommended for all pt with
ophthalmic herpes zoster
irrespective of their age or
Anterior segment of the left eye the severity of symptoms
showing the supra-temporal area of
scleromalacia
TREATMENT OF HERPES ZOSTER

Management of acute Herpes

Zoster infection
Treatment of ophthalmic
Herpes Zoster
Prevention of Postherpetic
neuralgia
Management of Postherpetic
neuralgia
MANAGEMENT OF ACUTE HZ
1. Antiviral medications:
Acyclovir (800 mg 5xd/7-10)
decreases pain especially in pt > 50
less expensive
Famcyclovir (500 or 750 mg 3xd/7xd)
within first 72 h,
decreases duration of rash by 1-2 d,
decreases pain only in pt with > 50
skin lesions
Valacyclovir and Famcyclovir
have similar effect
more preferred since dosing is 3 x d,
compared to Acyclovir 5 x d
more expensive
There are no data examining the
effect of Antiviral Tx >72 h of rash
onset
2. Steroidal treatment
ANTIVIRAL TREATMENT OF ACUTE HZ

The 50-50-50 rule

can be used as a guide for
antiviral treatment:
50 h or less since onset of
lesions,
50 y or older

More than 50 lesions

American Family Physician 2005

STEROID TREATMENT OF ACUTE HZ INFECTION

Studies have found that CS

combined with ACV
Caused greater reduction
of pain in 1st 2 wks but no
difference > 2 wks
Did not affect cutaneous
healing
Resulted in significant
benefit in quality of life at
30 days
Treatment of herpes
zoster with Antiviral meds
appear to be more effective
than treatment with
steroids.
PREVENTION OF HERPES ZOSTER

Varicella vaccine live attenuated

vacc containing 1350 plaque forming
units
Zoster vaccination -contains
18700-60000 plaque forming units
compared to varicella vac
A study of varicella vaccine in pt > 60
yo showed these results:
61 % reduction in pain and
discomfort
51 % reduction in incidence of HZ
67 % reduction in incidence of PHN
The vaccine has been approved for use
US (by FDA in May 2006 for adults
> 60 yo)
Europe, and Australia
ANTIVIRAL THERAPY IN PREVENTION
OF PHN
Acyclovir ( 7-10 d) :
reduces the incidence of pain at
1 to 3 M, but no difference > 3M
does not influence the incidence
or duration of PHN
Famcyclovir (for 7 d)
no effect on incidence of PHN

did reduce duration of pain

Valacyclovir compared to ACV

No difference on incidence of
PHN but pain lasted longer
among pt in ACV group.
Famcyclovir and Valacyclovir
showed similar results in
reducing the duration of PHN
PREVENTION OF POSTHERPETIC NEURALGIA

Steroid therapy have

no effect on preventing
PHN

TCA 25 mg, initiated

within 48 h of rash, and
continued for 90 d
reduced the risk or
PHN by 50 %
MANAGEMENT OF POSTHERPETIC NEURALGIA

TCA -amitriptyline
desipramine
Anticonvulsants: gabapentin
Potent analgesic opioids:
oxycodone
Lidocaine patch
Topical capsaicin
Intrathecal
methylprednisolone
(for persistent neuralgia
nonresponsive to oral and
topical therapy).
AAN 2004
KEY RECOMMENDATIONS FOR PRACTICE
(A) Physicians should treat acute herpes zoster with antiviral
medication within 72 hours of symptom onset to increase the rate
of healing and decrease the pain.
(A) Physicians should treat HZ with antiviral medications to
decrease the incidence and duration of PHN.
(A) TCA and gabapentin should be used to decrease the pain of
PHN.
(B) Amitriptyline should be used to decrease the risk of PHN in
older patients
(B) The lidocaine patch, capsaicin and opioids should be used to
decrease the pain from post herpetic neuralgia.

A = consistent, good quality patient-oriented evidence

B = evidence: inconsistent or limited-quality patient-oriented evidence
American Family Physician 2005
Curriculum Vitae
Pekerjaan:
Dokter IDT Puskesmas Belang, Kab. Minahasa, 1994.
Dokter Ka. Puskesmas Tolinggula, Kab Gorontalo, 1995-1998
Dokter magang di Bagian Saraf RSU Prof.dr. RD Kandou, Manado 2000-2002
Dokter PNS RSUD dr. M. Haulussy Ambon, 1999 -.

Pendidikan:
Dokter Umum : FK Universitas Sam Ratulangi 1994
Spesialis Saraf (SpS) : FK Universitas Indonesia 2008
Magister Kedokteran (MKed) : FK Universitas Indonesia 2008

Jabatan:
Ketua Sub Komite Pengendalian Mutu & Keselamatan Pasien
RSUD dr. M. Haulussy Ambon, 2009 - .
Timeline of Patophysiology
 SUMMARY OF TREATMENT OUTCOMES FOR HERPES ZOSTER:
SYSTEMATIC REVIEWS AND RANDOMIZED CONTROL TRIALS (RCTS)

Study Outcome

Wood, et al1 (n=1076), Acyclovir (Zovirax) 800 mg 5xd/7d is better than placebo for resolution of pain
meta-analysis

Beutner, et al2 (n=760), Valacyclovir (Valtrex) 1,000 mg 3xd/7d is better than acyclovir 800 mg 5xd/7d for
RCT resolution of pain.

Tyring, et al3 (n=419), Famciclovir (Famvir) 500 mg or 750 mg 3xd/7d increases rate of lesion healing
RCT better than placebo.

Shen, et al4 (n=55), RCT Famciclovir 250 mg 3xd/7d is equal to acyclovir 800 mg 5xd/7d for resolution of pain
and rate of lesion healing.

Shafran, et al5 (n=559), Famciclovir 750 mg 1xd/7d, 500 mg 2xd/7d, 250 mg 3xd/7d, and acyclovir 800 mg
RCT 5xd/7d are all equally effective for resolution of pain and rate of lesion healing.
American Family Physician 2005
REFERENCES
Clinical manifestations of varicella-zoster virus infection: Herpes zoster
UpToDate: www.uptodate.com

Treatment of herpes zoster

Canadian Family Physician
2008;54:373-7

Herpes Zoster and Postherpetic Neuralgia:

Prevention and Management
American Family Physician,
Sep 15, 2005, Volume 72, Number 6

Treatment of Herpes Zoster

American Family Physician
March 1, 2006

Treatment and prevention of herpes zoster

UpToDate: www.uptodate.com

www.google.com
 Enjoy the rest of the day!