To schedule an appointment with me:
5. For the pain of the actual area: ask for the following meds:
a. Capsaicin 0.025% (Zostrix) ointment 3x/d after rash heals
b. Qutenza patch: apply for 1 hour every 3 months
I hope this helps those with new onset Herpes Zoster.
Sandra Lora Cremers, MD, FACS
- ophthalmic involvement with acute or chronic ocular sequelae (herpes zoster ophthalmicus);
- bacterial superinfection of the lesions, usually due to Staphylococcus aureus and, less commonly, due to group A beta hemolytic streptococcus;
- cranial and peripheral nerve palsies; and
- visceral involvement, such as meningoencephalitis, pneumonitis, hepatitis, and acute retinal necrosis.
- with cancer, especially leukemia and lymphoma,
- with human immunodeficiency virus,
- who have undergone bone marrow or solid organ (renal, cardiac, liver, and lung) transplantation, or
- who are taking immunosuppressive medications, including steroids, chemotherapy, or transplant-related immunosuppressive medications.
- Most, but not all, studies found that more women than men develop herpes zoster [1,2]; the reason for a possible difference between women and men is not known.
- Some studies conducted in the United States and elsewhere found that herpes zoster is less common in blacks (by at least 50%) than in whites.
- Disease occurrence:
- The incidence for herpes zoster is approximately 4 cases per 1,000 U.S. population annually, age-adjusted to the 2000 U.S. population
- The incidence among people 60 years of age and older is about 10 cases per 1,000 U.S. population annually.
- There are an estimated one million cases of herpes zoster in the United States annually.
- Repeat episodes:
- Although 2nd and even 3rd episodes of herpes zoster can occur, the annual incidence of recurrence is not known.
- Approximately 1 to 4% of people with herpes zoster get hospitalized for complications.
- Older adults and people with compromised or suppressed immune systems are more likely to get hospitalized. About 30% of all people hospitalized with herpes zoster are those with compromised or suppressed immune systems.
- A recent study estimated that there are 96 deaths each year in which herpes zoster was the actual underlying cause (0.28 to 0.69 per 1 million population). Almost all the deaths occurred in elderly people or those with compromised or suppressed immune systems. 
- started increasing before varicella vaccine was introduced in the United States, and
- did not accelerate after the routine varicella vaccination program started.[5,8]
- In a study of children with leukemia, those who got varicella vaccine had a 67% lower risk of herpes zoster compared with children who had natural infection with wild-type VZV.
- Data on healthy children show a similar pattern of reduced risk of herpes zoster in those vaccinated against varicella.
- The number of older adults who have gotten varicella vaccine since it was licensed in 1995 is quite small. There is very little information on the risk of herpes zoster in people who got varicella vaccine as adults.
- CDC. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;57(05):1-30.
- Thomas SL, Hall AJ. What does epidemiology tell us about risk factors for herpes zoster? Lancet Infect Dis. 2004;4(1):26-33.
- Tseng HF, Smith N, Harpaz R, Bialek SR, Sy LS, Jacobsen SJ. Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease.JAMA. 2011 Jan 12;305(2):160-6.
- Mahamud A, Marin M, Nickell SP, Shoemaker T, Zhang JX, Bialek SR. Herpes zoster-related deaths in the United States: validity of death certificates and mortality rates, 1979-2007. Clin Infect Dis.2012 Oct;55(7):960-6.
- Leung J, Harpaz R, Molinari NA, Jumaan A, Zhou F. Herpes zoster incidence among insured persons in the United States, 1993-2006: evaluation of impact of varicella vaccination. Clinical Infectious Diseases. 2011;52(3):332-340.
- Yih W, Brooks D, Lett S, Jumaan A, Zhang Z, Clements K, Seward J. The Incidence of varicella and herpes zoster in Massachusetts as measured by the Behavioral Risk Factor Surveillance System (BRFSS) during a period of increasing varicella vaccine coverage. BMC Public Health. 2005;5(68).
- Jumaan AO, Yu O, Jackson LA, Bohlke K, Galil K, Seward JF. Incidence of herpes zoster, before and after varicella vaccination-associated decreases in the incidence of varicella. Journal of Infectious Diseases. 2005;191:2002-7.
- Hales CM, Harpaz R, Joesoef MR, Bialek SR (2013). Examination of links between herpes zoster incidence and childhood varicella vaccination. Annals of Internal Medicine. 159(11):739-45
- Russell ML, Dover DC, Simmonds KA, Svenson LW. Shingles in Alberta: before and after publicly funded varicella vaccination. Vaccine. DOI 10.1016/j.vaccine.2013.09.018.
- Weinmann S, Chun C, Schmid DS, Roberts M, Vandermeer M, Riedlinger K, et al. Incidence and clinical characteristics of herpes zoster among children in the varicella vaccine era, 2005–2009. Journal of Infection Diseases. 2013;208(11):1859-68.
- Hardy I, Gershon AA, Steinberg SP, LaRussa P. The incidence of zoster after immunization with live attenuated varicella vaccine. A study in children with leukemia. Varicella Vaccine Collaborative Study Group. N Engl J Med. 1991;325(22):1545-50.
- With resolution of the herpes zoster eruption, pain that continues for three months or more is defined as postherpetic neuralgia.
- Pain is variable, from discomfort to very severe, and may be described as burning, stabbing, or gnawing.
- Area of previous herpes zoster may show evidence of cutaneous scarring.
- Sensation may be altered over the areas involved, in the form of either hypersensitivity or decreased sensation.
- In rare cases, the patient might also experience muscle weakness, tremor, or paralysis if the nerves involved also control muscle movement.
- Race: It may influence susceptibility to herpes zoster. African Americans are one fourth as likely as Caucasians to develop this condition.
- Often an older, debilitated or immune compromised population.
- No laboratory work is usually necessary.
- Results of cerebrospinal fluid evaluation are abnormal in 61%.
- Pleocytosis is observed in 46%, elevated protein in 26%, and VZV DNA in 22%.
- These findings are not predictive of the clinical course of postherpetic neuralgia.
- Viral culture or immunofluorescence staining may be used to differentiate herpes simplex from herpes zoster in cases that are difficult to distinguish clinically.
- Antibodies to herpes zoster can be measured. A 4-fold increase has been used to support the diagnosis of subclinical herpes zoster (zoster sine herpete). However, a rising titer secondary to viral exposure rather than reactivation cannot be ruled out.
- Magnetic resonance imaging lesions attributable to herpes zoster were seen in the brain stem and cervical cord in 56% (9/16) of patients.
- At three months after onset of herpes zoster, 56% (5/9) of patients with an abnormal magnetic resonance image had developed postherpetic neuralgia.
- Of the seven patients who had no herpes-zoster-related lesions on the magnetic resonance image, none had residual pain.
TreatmentTreatment for postherpetic neuralgia depends on the type and characteristics of pain experienced by the patient. Pain control is essential to quality patient care; it ensures patient comfort. Possible options include:
- Antiviral agents, such as famciclovir, are given at the onset of attacks of herpes zoster to shorten the clinical course and to help prevent complications such as postherpetic neuralgia. However, they have no role to play following the acute attack once postherpetic neuralgia has become established.
- Locally applied topical agents
- Lidocaine skin patches. These are small, bandage-like patches that contain the topical, pain-relieving medication lidocaine. The patches, available by prescription, must be applied directly to painful skin and deliver relief for four to 12 hours. Patches containing lidocaine can also be used on the face, taking care to avoid mucus membranes e.g., the eyes, nose and mouth.
- Systemically delivered
- Opioids provide more potent pain control and the weaker members such as codeine may be available over the counter in combination with paracetamol (co-codamol). Other opioids are prescription-only and include higher dosages of codeine, tramadol, morphine or fentanyl. Most opioids have sedating properties, which are beneficial for patients who experience pain.
- Pain modification therapy
- Antidepressants. These drugs affect key brain chemicals, including serotonin and norepinephrine, that play a role in both depression and how the body interprets pain. Doctors typically prescribe antidepressants for postherpetic neuralgia in smaller doses than they do for depression. Low dosages of tricyclic antidepressants, including amitriptyline, seem to work best for deep, aching pain. They do not eliminate the pain, but they may make it easier to tolerate. Other prescription antidepressants (e.g., venlafaxine, bupropion and selective serotonin reuptake inhibitors) may be off-label used in postherpetic neuralgia and generally prove less effective, although they may be better tolerated than the tricyclics.
- Anticonvulsants. These agents are used to manage severe muscle spasms and provide sedation in neuralgia. They have central effects on pain modulation. Medications such asphenytoin (Dilantin, Phenytek), used to treat seizures, also can lessen the pain associated with postherpetic neuralgia. The medications stabilize abnormal electrical activity in the nervous system caused by injured nerves. Doctors often prescribe another anticonvulsant called carbamazepine (Carbatrol, Tegretol) for sharp, jabbing pain. Newer anticonvulsants, such as gabapentin (Neurontin) and lamotrigine (Lamictal), are generally tolerated better and can help control burning and pain.
- gabapentin enacarbil (HORIZANT), an alpha-2-delta-1 ligand and a prodrug of gabapentin, was approved by the FDA in 2012 for the management of postherpetic neuralgia.
- Corticosteroids are commonly prescribed but a Cochrane Review found limited evidence and no benefit.[needs update]
- Other non-pharmacological treatments for postherpetic neuralgia include the following:
- Relaxation techniques. These can include breathing exercises, visualization and distraction.
- Cold therapy. Cold packs can be used.
- Transcutaneous Electrical Nerve Stimulation. This involves the stimulation of peripheral nerve endings by the delivery of electrical energy through the surface of the skin.
- Spinal cord stimulator. The electrical stimulation of the posterior spinal cord works by activating supraspinal and spinal inhibitory pain mechanisms.
In some cases, treatment of postherpetic neuralgia brings complete pain relief. But most people still experience some pain, and a few do not receive any relief. Although some people must live with postherpetic neuralgia the rest of their lives, most people can expect the condition to gradually disappear on its own within five years.
PrognosisThe natural history of postherpetic neuralgia involves slow resolution of the pain syndrome. Most people who develop postherpetic neuralgia respond to agents such as tricyclic antidepressants. A subgroup of affected individuals may develop severe, long-lasting pain that does not respond to medical therapy.
PreventionPrimary preventionIn 1995, the Food and Drug Administration (FDA) approved the Varicella vaccine to prevent chickenpox. Its effect on postherpetic neuralgia is still unknown. The vaccine—made from a weakened form of the varicella-zoster virus—may keep chickenpox from occurring in nonimmune children and adults, or at least lessen the risk of the chickenpox virus lying dormant in the body and reactivating later as shingles. If shingles could be prevented, postherpetic neuralgia could be completely avoided.
In May 2006 the Advisory Committee on Immunization Practices approved a new vaccine by Merck (Zostavax) against shingles. This vaccine is a more potent version of the chickenpox vaccine, and evidence shows that it reduces the incidence of postherpetic neuralgia. The CDC recommends use of this vaccine in all persons over 60 years old.Secondary preventionAn April 2013 Cochrane Collaboration meta-analysis of 6 randomized controlled trials (RCTs) investigating oral antiviral medications given within 72 hours after the onset of herpes zoster rash in immunocompetent people for preventing postherpetic neuralgia (PHN) found no significant difference between placebo and acyclovir. Combining four RCTs, 44.1% of the acyclovir treatment group developed herpetic neuralgia whereas 53.3% of the placebo group developed herpetic neuralgia. Heterogeneity between the four RCTs was moderate: Chi2 =3.36, df = 2 (P=0.19); I2 = 40%. Additionally, there was no significant difference in preventing the incidence of PHN found in the one RCT included in the meta-analysis that compared placebo to PO famciclovir treatment within 72 hours of HZ rash onset. Studies using valaciclovir treatment were not included in the meta-analysis. PHN was defined as pain at the site of the dermatomic rash at 120 days after the onset of rash, and incidence was evaluated at 1, 4, and 6 months after rash onset. There was a slight reduction in the incidence of pain at 4 weeks after the onset of rash in the aciclovir group (153 study participants with pain out of 347 study participants in the aciclovir group) versus the placebo group (184 study participants with pain out of 345 study participants in the placebo group). Patients who are prescribed PO antiviral agents after the onset of rash should be informed that their chances of developing PHN are no different than those not taking PO antiviral agents.A randomized controlled trial found that amitriptyline 25 mg per night for 90 days starting within two days of onset of rash can reduce the incidence of postherpetic neuralgia from 35% to 16% (number needed to treat is 6).Research directions
- Gallium maltolate in a cream or ointment base has been studied in a case report as a treatment of refractory postherpetic trigeminal neuralgia.
- Gharibo, Christopher; Kim, Carolyn (December 2011). “Neuropathic Pain of Postherpetic Neuralgia” (PDF). Pain Medicine News. McMahon Publishing. Retrieved 6 October 2014.
- Brian J. Hall, John C. Hall. “Infectious diseases in the skin”. Sauer’s Manual of Skin Diseases. Lippincott Williams & Wilkins, 2010. p. 232.
- Weaver, B A (2009). “Herpes zoster overview: natural history and incidence.” (PDF). J Am Osteopath Assoc 109 (6 (Suppl 2)): S2–6. PMID Retrieved 6 October 2014.
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- Chen N, Yang M, He L, Zhang D, Zhou M, Zhu C (2010). He, Li, ed. “Corticosteroids for preventing postherpetic neuralgia”. Cochrane Database Syst Rev (12): CD005582.doi:.
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- Harke H, Gretenkort P, Ladleif HU, Koester P, Rahman S (2002). “Spinal cord stimulation in postherpetic neuralgia and in acute herpes zoster pain”. Anesthesia & Analgesia 94 (3): 694–700.doi:
- Chen N, Li Q, Zhang Y, Zhou M, Zhou D, He L (2011). He, Li, ed. “Vaccination for preventing postherpetic neuralgia”. Cochrane Database Syst Rev (3): CD007795
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- Bowsher D (1997). “The effects of pre-emptive treatment of postherpetic neuralgia with amitriptyline: a randomized, double-blind, placebo-controlled trial”. Journal of pain and symptom management 13 (6): 327–31.
- Bernstein, L.R. (2013). “Gallium, therapeutic effects” (PDF). In Kretsinger, R.H.; Uversky, V.N.; Permyakov, E.A. Encyclopedia of Metalloproteins. New York: Springer. pp. 823–835. ISBN 978-1-4614-1532-9.