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 7
6 5 4 3 2 1 0

8.8

2.0 01 MONTH 03 MONTHS 01 YEAR

PATIENTS < 60 YRS

45

40
35

40.8

30
25 20 15 10 5 0 01 MONTH 03 MONTHS 01 YEAR 13.0 7.8 INCIDENCE

PATIENTS > 60 YRS

PATHOPHYSIOLOGY OF PHN

Varicella-Zoster Virus

Reactivation- HZ

Replication of virus in Ganglionic nerve cells

Migration along Peripheral Afferent Sensory Pathways

Demyelinatin of Afferent fibres & Dorsal horn neuronal plasticity

Loss of inhibition and increased activity within sensory afferent fibres

Post-Herpetic Neuralgia

neurochemical, physiological and anatomical modifications to afferent and central neurons

afferent terminal sprouting and inhibitory interneuron loss

Na channel accumulation

Hyperexcitability

increased NMDA glutamate receptor-dependent excitability of spinal dorsal horn neurons

neuropathic pain state of PHN

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 have 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