Management of herpes zoster (shingles) and postherpetic neuralgia

Modelling the impact and cost effectiveness of universal varicella vaccination in England

INTRODUCTION

Two distinct diseases are attributable to the varicella zoster virus, varicella (chickenpox) and zoster (shingles). This study assesses the impact and cost-effectiveness of a childhood varicella vaccination program in England.

METHODS

We use an age-structured dynamic transmission model and a health economic decision tree. The model incorporates recent data on varicella and zoster epidemiology, including the effects of exogenous boosting on zoster incidence. By simulating various vaccination strategies, including routine and catch-up programs, the study evaluates the potential reduction in varicella and zoster cases due to vaccination and the associated vaccine cost-effectiveness (from the NHS perspective).

RESULTS

We find that a two-dose varicella vaccination program could significantly reduce varicella incidence, potentially achieving near-elimination if high coverage rates are maintained. However, the model also predicts a temporary increase in zoster incidence due to reduced natural boosting from varicella exposure; this is partly mitigated by the current zoster vaccination program and the effect is much less substantial than previously estimated. Cost-effectiveness analyses reveal that all vaccination strategies modelled are cost-effective at typical thresholds, with the routine vaccination scenario being the most economically advantageous. Sensitivity analyses demonstrate that vaccine price and varicella treatment costs are the primary drivers of cost-effectiveness.

CONCLUSION

The study supports the introduction of a childhood varicella vaccination program in England, which offers substantial health benefits and is highly likely to be cost-effective.

Relieving postherpetic neuralgia pain via gabapentin-loaded bigels as an auspicious topical drug delivery system

BACKGROUND

Over the past decades, a substantial portion of the population worldwide has been infected with varicella zoster and most cases developed shingles. Unfortunately, shingles is usually accompanied by postherpetic neuralgia, which may persist for months to years after the resolution of the viral infection.

OBJECTIVES

Gabapentin is an orally gamma-aminobutyric acid analogue approved by the Food and Drug Administration to manage shingles postherpetic neuralgia. However, gabapentin shows nonlinear pharmacokinetics, with variable absorption and bioavailability along with its short half-life and long side effects that may include dizziness and somnolence, which calls for an appropriate topical dosage form. Bigels are unique semisolid dosage forms with boosted penetrability and satisfactory hydrophilic texture.

METHODS

The current work pointed to formulating gabapentin-loaded bigels for the treatment of postherpetic neuralgia, where the analysis and optimization of design were performed via Design-Expert®.

RESULTS AND CONCLUSIONS

The selected bigel (F5), incorporating 400 mg Span 60, 1000 mg Tween 80, and 1000 mg Transcutol, displayed spherical nanosized particles with acceptable viscosity and spreadability. Subsequent topical application of the selected bigel on the skin of Wistar rats, F5, demonstrated a boosted accumulation of gabapentin in the skin similar to PLO gel but superior to the drug solution. Furthermore, a histopathological study demonstrated the biosafety of the selected bigel when applied topically. Accordingly, gabapentin-loaded bigel would be considered a potentially topical dosage form for the delivery of gabapentin for the management of postherpetic neuralgia.

Rodent models of postherpetic neuralgia: How far have we reached?

Background

Induced by varicella zoster virus (VZV), postherpetic neuralgia (PHN) is one of the common complications of herpes zoster (HZ) with refractory pain. Animal models play pivotal roles in disclosing the pain mechanisms and developing effective treatments. However, only a few rodent models focus on the VZV-associated pain and PHN.

Objective

To summarize the establishment and characteristics of popular PHN rodent models, thus offer bases for the selection and improvement of PHN models.

Design

In this review, we retrospect two promising PHN rodent models, VZV-induced PHN model and HSV1-induced PHN model in terms of pain-related evaluations, their contributions to PHN pathogenesis and pharmacology.

Results

Significant difference of two PHN models is the probability of virus proliferation; 2) Most commonly used pain evaluation of PHN model is mechanical allodynia, but pain-induced anxiety and other behaviours are worth noting; 3) From current PHN models, pain mechanisms involve changes in virus gene and host gene expression, neuroimmune-glia interactions and ion channels; 4) antiviral drugs and classical analgesics serve more on the acute stage of herpetic pain.

Conclusions

Different PHN models assessed by various pain evaluations combine to fulfil more comprehensive understanding of PHN.

Varicella zoster virus cerebellitis without skin manifestations in an immunocompetent adult

The varicella zoster virus (VZV) is a ubiquitous, neurotropic pathogen capable of reactivation from sensory ganglion cells to cause dermatomal herpes zoster infection, alongside a range of pathologies within the central nervous system. The presence of VZV cerebellitis without skin manifestations, however, is exceedingly rare in immunocompetent adults.We report a case of VZV cerebellitis in an immunocompetent woman in her 70s, in the absence of a rash. The patient presented with a 2-week history of progressive gait ataxia, headache and mild confusion. Serological tests and neuroimaging were unremarkable. Diagnosis was confirmed through cerebrospinal fluid (CSF) analysis which revealed lymphocytosis and the presence of VZV DNA on PCR analysis. The patient showed symptomatic improvement following empirical acyclovir treatment, corroborated by favourable CSF analysis 10 days post-treatment initiation.Infective aetiology, including VZV, should be considered in patients presenting with acute cerebellar ataxia, even in immunocompetent adults with an absence of dermatological signs.

Current scenario and future applicability of antivirals against herpes zoster

Herpes zoster (HZ) is a common disease in the aging population and immunocompromised individuals, with a lifetime risk of 20%-30% that increases with age. HZ is caused by reactivation of the varicella-zoster virus (VZV), which remains latent in the spinal dorsal root ganglia and cranial sensory ganglia after resolution of the primary VZV infection. The main focus of HZ management is rapid recovery from VZV infection as well as the reduction and prevention of zoster-associated pain (ZAP) and postherpetic neuralgia (PHN). The use of antivirals against VZV is essential in the treatment of HZ. However, limited antivirals are only licensed clinically for the treatment of HZ, including acyclovir, valacyclovir, famciclovir, brivudine, and amenamevir. Fortunately, some new antivirals against different types of Herpesviridae have been investigated and suggested as novel drugs against VZV. Therefore, this review focuses on discussing the difference in efficacy and safety in the currently licensed antivirals for the treatment of HZ, the applicability of future novel antivirals against VZV, and the preventive or therapeutic effects of these antivirals on ZAP or PHN.

Printed graphene-based electrochemical sensor with integrated paper microfluidics for rapid lidocaine detection in blood

Topical lidocaine patches are commonly used to relieve pain and suffering in various clinical and household settings. Despite its extensive use, excessive skin absorption during numbing or pain reduction procedures can cause systemic toxicity, which can lead to life-threatening conditions. Rapid and reliable monitoring of escalating levels of lidocaine in the blood could help management/prevention of lidocaine overdose and its associated complications. To address this need, here we have developed a disposable point-of-care (POC) diagnostic platform composed of an integrated graphene-based electrochemical sensor with paper-based microfluidics for rapid detection of lidocaine levels in serum and blood samples. The fabrication process takes advantage of advanced, scalable manufacturing techniques, including printing, laser processing, and nondestructive near infrared (NIR) drying. The sensitivity tests of the platform revealed a sensitivity of ∼0.2 μA μM^-1 towards lidocaine concentrations in the clinically relevant range (1-100 μM) in both complex matrix fluids of serum and blood with high cross specificity in the presence of the interfering analytes. This proof-of-concept platform could be regarded as the first step toward the development of low-cost and translational POC devices that could help in better pain management and reduce potential side effects or misuse of analgesics.

Identifying optimal vaccination scenarios to reduce varicella zoster virus transmission and reactivation

BACKGROUND

Varicella zoster virus (VZV) is one of the eight known human herpesviruses. Initial VZV infection results in chickenpox, while viral reactivation following a period of latency manifests as shingles. Separate vaccines exist to protect against both initial infection and subsequent reactivation. Controversy regarding chickenpox vaccination is contentious with most countries not including the vaccine in their childhood immunization schedule due to the hypothesized negative impact on immune-boosting, where VZV reactivation is suppressed through exogenous boosting of VZV antibodies from exposure to natural chickenpox infections.

METHODS

Population-level chickenpox and shingles notifications from Thailand, a country that does not vaccinate against either disease, were previously fitted with mathematical models to estimate rates of VZV transmission and reactivation. Here, multiple chickenpox and shingles vaccination scenarios were simulated and compared to a model lacking any vaccination to analyze the long-term impacts of VZV vaccination.

RESULTS

As expected, simulations suggested that an introduction of the chickenpox vaccine, at any coverage level, would reduce chickenpox incidence. However, chickenpox vaccine coverage levels above 35% would increase shingles incidence under realistic estimates of shingles coverage with the current length of protective immunity from the vaccine. A trade-off between chickenpox and shingles vaccination coverage was discovered, where mid-level chickenpox coverage levels were identified as the optimal target to minimize total zoster burden. Only in scenarios where shingles vaccine provided lifelong immunity or coverage exceeded current levels could large reductions in both chickenpox and shingles be achieved.

CONCLUSIONS

The complicated nature of VZV makes it impossible to select a single vaccination scenario as universal policy. Strategies focused on reducing both chickenpox and shingles incidence, but prioritizing the latter should maximize efforts towards shingles vaccination, while slowly incorporating chickenpox vaccination. Alternatively, countries may wish to minimize VZV complications of both chickenpox and shingles, which would lead to maximizing vaccine coverage levels across both diseases. Balancing the consequences of vaccination to overall health impacts, including understanding the impact of an altered mean age of infection for both chickenpox and shingles, would need to be considered prior to any vaccine introduction.

Polyphenols and their potential role to fight viral diseases: An overview

Fruits, vegetables, spices, and herbs are a potential source of phenolic acids and polyphenols. These compounds are known as natural by-products or secondary metabolites of plants, which are present in the daily diet and provide important benefits to the human body such as antioxidant, anti-inflammatory, anticancer, anti-allergic, antihypertensive and antiviral properties, among others. Plentiful evidence has been provided on the great potential of polyphenols against different viruses that cause widespread health problems. As a result, this review focuses on the potential antiviral properties of some polyphenols and their action mechanism against various types of viruses such as coronaviruses, influenza, herpes simplex, dengue fever, and rotavirus, among others. Also, it is important to highlight the relationship between antiviral and antioxidant activities that can contribute to the protection of cells and tissues of the human body. The wide variety of action mechanisms of antiviral agents, such as polyphenols, against viral infections could be applied as a treatment or prevention strategy; but at the same time, antiviral polyphenols could be used to produce natural antiviral drugs. A recent example of an antiviral polyphenol application deals with the use of hesperidin extracted from Citrus sinensis. The action mechanism of hesperidin relies on its binding to the key entry or spike protein of SARS-CoV-2. Finally, the extraction, purification and recovery of polyphenols with potential antiviral activity, which are essential for virus replication and infection without side-effects, have been critically reviewed.

Non-drug pain relievers active on non-opioid pain mechanisms

This review is aimed to summarize the pain-relieving effect of non-drug substances, mostly prescribed as integrators in treatment of pain, including especially in chronic postoperative pain (CPSP) and in chronic back pain after acute episodes. Their use reflects the fact that the current treatments for these syndromes continue to pose problems of unsatisfactory responses in a significant portion of patients and/or of an excess of side effects like those noted in the present opioid crisis. As integrators are frequently introduced into the market without adequate clinical testing, this review is aimed to collect the present scientific evidence either preclinical or clinical for their effectiveness. In particular, we reviewed the data on the use of: B vitamins; vitamin C; vitamin D; alpha lipoic acid (ALA); N-acetylcysteine; acetyl L-carnitine; curcumin; boswellia serrata; magnesium; coenzyme Q10, and palmitoylethanolamide. The combination of preclinical findings and clinical observations strongly indicate that these compounds deserve more careful attention, some of them having interesting clinical potentials also in preventing chronic pain after an acute episode. In particular, examining their putative mechanisms of action it emerges that combinations of few of them may exert an extraordinary spectrum of activities on a large variety of pain-associated pathways and may be eventually used in combination with more traditional pain killers in order to extend the duration of the effect and to lower the doses. Convincing examples of effective combinations against pain are vitamin B complex plus gabapentin for CPSP, including neuropathic pain; vitamin B complex plus diclofenac against low back pain and also in association with gabapentin, and ALA for burning mouth syndrome. These as well as other examples need, however, careful controlled independent clinical studies confirming their role in therapy.

Measuring herpes zoster disease burden in São Paulo, Brazil: a clinico-epidemiological single-center study

OBJECTIVES

Herpes zoster is characterized by acute neuritis and post-herpetic neuralgia. Currently, data concerning the zoster-associated impact on quality of life and healthcare resource utilization in Brazil are scarce. This study measured the zoster-associated burden in a Brazilian population.

METHODS

This was a prospective, observational, single-cohort study conducted in a primary hospital's emergency room in São Paulo, Brazil. Patients enrolled at various timepoints during a zoster episode were followed over 180 days. The Zoster Brief Pain Inventory and the Initial Zoster Impact Questionnaire assessed zoster-associated pain. The EuroQoL assessed the impact of herpes zoster and/or zoster-associated pain on quality of life. Healthcare resource utilization was assessed by patient-reported questionnaires.

RESULTS

One-hundred forty-six zoster patients were enrolled [mean (SD) age of 69.9 (10.9) years]. Mean (SD) worst pain scores decreased from 5.3 (3.5) at baseline to 1.9 (3.0) 180 days following rash onset. Mean (SD) EuroQoL scores significantly decreased from 0.9 (0.2) before rash appearance to 0.7 (0.2) after rash onset (p<0.001), followed by gradual improvements in quality of life over 180 days, with pre-herpes zoster quality of life achieved at the end of the observation period. The majority of patients purchased prescription medications (89.7%) and required doctor's office visits (65.8%) for zoster episodes.

CONCLUSIONS

Herpes zoster is associated with a significant disease burden, including zoster-associated pain, impaired quality of life and increased healthcare resource utilization in Brazil. These results support the implementation of early intervention and prevention programs such as vaccinations to reduce the herpes zoster-associated disease burden in Brazil.

Trends in herpes zoster epidemiology in Germany based on primary care sentinel surveillance data, 2005-2016

Herpes zoster (HZ) is caused by reactivation of the varicella-zoster-virus (VZV). Childhood varicella vaccination, as recommended in Germany in 2004, may reduce the risk of HZ in vaccinated children but also virus circulation and thus the booster possibility of latent infected persons. In this context we analyzed age-specific trends in HZ epidemiology in Germany using data on HZ-associated outpatient consultations in participating sentinel sites and HZ-associated cases in all hospitals since 2005. We analyzed two separate time periods that differed in sentinel management and data integrity. For the period 2005-2010, we found a decrease in HZ-associated outpatient consultations in 1- to 4-year-olds (IRR = 0.72, 95%CI 0.63-0.81, p<0.001). For the period 2013-2016, we observed a decrease in HZ-associated outpatient consultations in 10- to 14-year-olds (IRR = 0.85, 95%CI 0.78-0.93, p<0.01). Moreover, we detected an increase in the age groups 20 years and older except for the group 30-39 years. HZ-associated hospitalizations showed similar trends for the second time period (here 2012-2015). The decrease in HZ-associated outpatient consultations and hospitalizations in children started and continued over cohorts eligible for varicella vaccination and could be a result of their reduced HZ-risk. Whether the observed steady increasing HZ incidences for adults are associated with the varicella vaccination in children remains unclear and could not be investigated with our data.

Executive summary of the Clinical Guidelines of Pharmacotherapy for Neuropathic Pain: second edition by the Japanese Society of Pain Clinicians

Neuropathic pain has a substantial effect on quality of life (QOL). The Japanese Society of Pain Clinicians (JSPC) has developed clinical guidelines of pharmacotherapy for neuropathic pain. These guidelines offer clarity on recommendations based on both the most recent scientific evidence and expert opinions. Understanding the concept, disease entity, and burden of neuropathic pain, as well as its screening and diagnosis are important steps before starting pharmacotherapy. As well as other guidelines, the guidelines propose several lines of pharmacotherapies in a step-wise manner. To name a few different points, our guidelines propose an extract from inflamed cutaneous tissue of rabbits inoculated with vaccinia virus, which has been found to be effective for post-herpetic neuralgia in Japan, as one of the second-line drugs. When prescribing opioid analgesics, proposed as the third-line drugs, for neuropathic pain, the guidelines recommend physicians continue evaluations on either abuse or addiction. The guidelines do not recommend concomitant use of nonsteroidal anti-inflammatory drugs and acetaminophen because of lack of clinical evidence of their efficacy. If patients do not respond well to pharmacotherapy, which is prescribed in a step-wise manner, other treatment strategies should be considered to improve patients’ activities of daily living and QOL.

The Effectiveness and Safety of Topical Capsaicin in Postherpetic Neuralgia: A Systematic Review and Meta-analysis

In particular, neuropathic pain is a major form of chronic pain. This type of pain results from dysfunction or lesions in the central and peripheral nervous system. Capsaicin has been traditionally utilized as a medicine to remedy pain. However, the effectiveness and safety of this practice is still elusive. Therefore, this systematic review aimed to investigate the effect of topical capsaicin as a pain-relieving agent that is frequently used in pain management. In brief, all the double-blinded, randomized placebo- or vehicle-controlled trials that were published in English addressing postherpetic neuralgia were included. Meta-analysis was performed using Revman^® version 5.3. Upon application of the inclusion and exclusion criteria, only six trials fulfilled all the criteria and were included in the review for qualitative analysis. The difference in mean percentage change in numeric pain rating scale score ranges from -31 to -4.3. This demonstrated high efficacy of topical capsaicin application and implies that capsaicin could result in pain reduction. Furthermore, meta-analysis was performed on five of the included studies. All the results of studies are in favor of the treatment using capsaicin. The incidence of side effects from using topical capsaicin is consistently higher in all included studies, but the significance of safety data cannot be quantified due to a lack of p-values in the original studies. Nevertheless, topical capsaicin is a promising treatment option for specific patient groups or certain neuropathic pain conditions such as postherpetic neuralgia.

Prevention of herpes zoster and its complications: from the clinic to the real-life experience with the vaccine

The erpes zoster is an acute viral illness characterized by a vesicular rash of unilateral distribution, which can eventually cause severe complications, such as post-herpetic neuralgia, ophthalmic zoster, stroke or other neurological complications. In Europe, an incidence of between 2.0 and 4.6 cases per 1000 person-years is estimated, with an increase after 50 years of age. Currently, the therapeutic options for are only partially effective in limiting the acute phase, while the management of complications is frequently complex and not satisfactory. The overall burden of the disease and the elevated costs associated with diagnosis and clinical and therapeutic management led to the development of a new preventive approach through a live attenuated virus vaccine. The vaccine now available decreases the incidence of the disease, post-herpetic neuralgia and the burden of illness. Moreover, the vaccine is safe and well tolerated and it seems to confer long-term protection. Based on the clinical results and evidence provided by the Health Technology Assessment, several countries introduced immunization although with different recommendations and methods of funding.

Anti-cytokine autoantibodies in postherpetic neuralgia

BACKGROUND

The mechanisms by which varicella zoster virus (VZV) reactivation causes postherpetic neuralgia (PHN), a debilitating chronic pain condition, have not been fully elucidated. Based on previous studies identifying a causative role for anti-cytokine autoantibodies in patients with opportunistic infections, we explored this possibility in PHN.

METHODS

Sera from herpes zoster (HZ) patients without and with PHN (N = 115 and 83, respectively) were examined for the presence of autoantibodies against multiple cytokines, and other known autoantigens. In addition, a cohort of patients with complex regional pain syndrome or neuropathic pain was tested for autoantibodies against selected cytokines. Antibody levels against VZV, Epstein Barr virus, and herpes simplex virus-2 were also measured in the HZ and PHN patients. Patient sera with high levels of anti-cytokine autoantibodies were functionally tested for in vitro neutralizing activity.

RESULTS

Six PHN subjects demonstrated markedly elevated levels of single, autoantibodies against interferon-α, interferon-γ, GM-CSF, or interleukin-6. In contrast, the HZ and the pain control group showed low or no autoantibodies, respectively, against these four cytokines. Further analysis revealed that one PHN patient with high levels of anti-interleukin-6 autoantibodies had a markedly depressed antibody level to VZV, potentially reflecting poor T cell immunity against VZV. In vitro functional testing revealed that three of the five anti-cytokine autoantibody positive PHN subjects had neutralizing autoantibodies against interferon-α, GM-CSF or interleukin-6. In contrast, none of the HZ patients without PHN had neutralizing autoantibodies.

CONCLUSIONS

These results suggest the possibility that sporadic anti-cytokine autoantibodies in some subjects may cause an autoimmune immunodeficiency syndrome leading to uncontrolled VZV reactivation, nerve damage and subsequent PHN.

Prevention of post-herpetic neuralgia using transcutaneous electrical nerve stimulation

BACKGROUND

Post-herpetic neuralgia (PHN) is the most common complication of herpes zoster (HZ) and is difficult to treat. The role of antiviral agents and nonpharmacologic procedures in preventing PHN is not entirely clear. Recent retrospective study showed that transcutaneous electrical nerve stimulation (TENS) may completely prevent PHN. The aim of our study was to identify predictors for PHN and evaluate the treatment with antiviral agents and TENS.

METHODS

We conducted a multicenter prospective, randomized intervention study in patients with a new onset of HZ. Immunocompromised patients were excluded. Patients were randomly assigned to four groups (TENS, Antiviral agents, TENS and Antiviral agents, and Control Group). At the inclusion, the following criteria were recorded: age, gender, duration of pain before the onset of the rash, the number of efflorescence, the intensity of pain, and the analgesic prescribed. During the follow-up, we recorded a spontaneous pain sensation, pain intensity, and presence of allodynia, hyperalgesia, or paraesthesia.

RESULTS

With each additional year of age, the odds for the presence of PHN with unchanged values of other predictors increase (odds ratio (OR) = 1.03 [1.01; 1.05], p = 0.001). The same is true for the initial intensity of the pain (OR = 1.25 [1.09; 1.43], p = 0.002). The odds for acute and subacute herpetic neuralgia are greater than for PHN. The odds for subacute herpetic neuralgia are the lowest in the group treated with TENS (OR = 0.15 [0.05; 0.47], p = 0.001).

CONCLUSIONS

PHN cannot be completely prevented. TENS as a single therapy was found the most successful among the tested treatments in reducing the incidence of subacute herpetic neuralgia.

Prevention of shingles by varicella zoster virus vaccination

Herpes zoster is caused by reactivation from previous varicella zoster virus (VZV) infection, and affects millions of people worldwide. It primarily affects older adults and those with immune system dysfunction, most likely as a result of reduced or lost VZV-specific cell-mediated immunity. Complications include post-herpetic neuralgia, a potentially debilitating and chronic pain syndrome. Current treatment of herpes zoster and post-herpetic neuralgia involves antiviral agents and analgesics, and is associated with significant economic cost. Results from several clinical trials have determined that a live, attenuated VZV vaccine using the Oka/Merck strain (Zostavax) is safe, elevates VZV-specific cell-mediated immunity, and significantly reduces the incidence of herpes zoster and post-herpetic neuralgia in people over 60 years of age. Regulatory approval has recently been obtained and once launched, it is expected that this vaccine will significantly reduce the morbidity and financial costs associated with herpes zoster. Durability of vaccine response and possible booster vaccination will still need to be determined.

Health economic evidence of 5% lidocaine medicated plaster in post-herpetic neuralgia

BACKGROUND

Post-herpetic neuralgia (PHN) is the most common and most debilitating complication of herpes zoster, and involves considerable associated costs.

OBJECTIVE

This paper presents results from nine health economic studies undertaken in eight European countries that compared lidocaine medicated plaster with gabapentin and/or pregabalin in PHN. It aims to support the increasing need for published cost-effectiveness data for health care decision-making processes in Europe.

METHODS

All studies were based on a similar core Markov model with data derived from clinical trials, local Delphi panels, and official national price and tariff lists. The main outcome measure was cost per quality-adjusted life year gained; time without pain or intolerable adverse events was also included as a secondary outcome measure. All studies focused on an elderly population of patients with PHN who had insufficient pain relief with standard analgesics and could not tolerate or had contraindications to tricyclic antidepressants.

RESULTS

Despite considerable differences in many of the variables used, the results showed remarkable similarity and suggested that use of lidocaine medicated plaster offered cost-savings in many of the countries studied, where it proved a highly cost-effective alternative to both gabapentin and pregabalin.

CONCLUSION

Lidocaine medicated plaster is a cost-effective alternative to gabapentin and pregabalin in the treatment of PHN. These savings are largely the result of the superior safety profile of the lidocaine medicated plaster.

The use of narrow band ultraviolet light B in the prevention and treatment of postherpetic neuralgia (a pilot study)

Background:

Postherpetic neuralgia (PHN) is a common complication of herpes zoster that is frequently unresponsive to most of the available treatment modalities. Broad band ultraviolet B radiation (UVB) has a well-known anti-inflammatory effect. Moreover, it decreases neural damage and cutaneous nerve density. It was found that broad band UVB might have a role in the prevention and treatment of PHN.

Aim:

This study was carried out to evaluate the effect ofnarrow band UVB (nbUVB) in the treatment PHN.

Patients and Methods:

The study included 17 patients with distressing post herpetic neuralgia. Patients were evaluated using the Verbal Rating Scale (VRS). The patients received nbUVB sessions, three times a week, for a total of 15 sessions or until the pain disappeared. Patients were followed up for a period of 3 months after the end of therapy.

Results:

Using intention to treat analysis, more than 50% improvement was achieved in 6 (35.29%) and 8 (47.06%) patients, at the end of therapy and after 3 months follow up, respectively. An improvement less that 50% was achieved in 11 (64.71%) and 9 (52.94%) patients, at the end of therapy and after 3 months follow up, respectively. The pain severity assessed by the VRS significantly improved both at the end of sessions (P = 0.005) and after 3 months follow up (P = 0.005).

Conclusion:

nbUVB may be of beneficial use in the treatment of PHN.

Limitation:

Small number of patients and limited follow-up period.

The impact of herpes zoster and post-herpetic neuralgia on quality-of-life

BACKGROUND

The potentially serious nature of herpes zoster (HZ) and the long-term complication post-herpetic neuralgia (PHN) are often underestimated. One in four people will contract herpes zoster in their lifetime, with this risk rising markedly after the age of 50 years, and affecting one in two in elderly individuals. Pain is the predominant symptom in all phases of HZ disease, being reported by up to 90% of patients. In the acute phase, pain is usually moderate or severe, with patients ranking HZ pain as more intense than post-surgical or labour pains. Up to 20% of patients with HZ develop PHN, which is moderate-to-severe chronic pain persisting for months or years after the acute phase. We review the available data on the effect of HZ and PHN on patients' quality-of-life.

DISCUSSION

Findings show that HZ, and particularly PHN, have a major impact on patients' lives across all four health domains--physical, psychological, functional and social. There is a clear correlation between increasing severity of pain and greater interference with daily activities. Non-pain complications such as HZ ophthalmicus can increase the risk of permanent physical impairment. Some elderly individuals may experience a permanent loss of independence after an acute episode of HZ. Current challenges in the management of HZ and PHN are highlighted, including the difficulty in administering antiviral agents before pain becomes established and the limited efficacy of pain treatments in many patients. We discuss the clinical rationale for the HZ vaccine and evidence demonstrating that the vaccine reduces the burden of the disease. The Shingles Prevention Study, conducted among >38,000 people aged >or=60 years old, showed that the HZ vaccine significantly reduces the burden of illness and the incidence of both HZ and PHN. In the entire study population, zoster vaccination reduced the severity of interference of HZ and PHN with activities of daily living by two-thirds, as measured by two questionnaires specific to HZ.

SUMMARY

A vaccination scheme may positively impact the incidence and course of HZ disease, thereby improving patients' quality-of-life.

Adjuvant topical therapy with a cannabinoid receptor agonist in facial postherpetic neuralgia

BACKGROUND

Postherpetic neuralgia is a frequent adverse event in herpes zoster patients and difficult to treat. Conventional analgetic therapy often fails to reduce the burning pain transmitted by unmyelinated nerve fibers. These nerves express cannabinoid receptors which exert a role in modulation of nociceptive symptoms. Therefore, topical therapy with cannabinoid receptor agonist seems likely to suppress local burning pain.

PATIENTS AND METHODS

In an open-labeled trial, 8 patients with facial postherpetic neuralgia received a cream containing the cannabinoid receptor agonist N-palmitoylethanolamine. The course of symptoms was scored with the visual analog scale.

RESULTS

5 of 8 patients (62.5 %) experienced a mean pain reduction of 87.8 %. Therapy was tolerated by all patients. No unpleasant sensations or adverse events occurred.

CONCLUSIONS

Topical cannabinoid receptor agonists are an effective and well-tolerated adjuvant therapy option in postherpetic neuralgia.

Postherpetic neuralgia in the elderly

Postherpetic neuralgia (PHN) is the most common complication of herpes zoster (HZ) or 'shingles' and affects a significant proportion of HZ patients with the disease, with the elderly being most frequently and seriously affected. Characterised by various types of pain (constant, intermittent and stimulus evoked) that persist between 3 months and many years after the resolution of the HZ rash, PHN can have a severe impact on the patient's quality of life and functional ability. PHN remains highly resistant to current treatments. In this review, we discuss the epidemiology, clinical features and management of PHN in the elderly and the potential of vaccination against varicella zoster virus as a means to prevent HZ, and thus decrease the incidence and severity of PHN.

Efficacy and tolerability of a 5% lidocaine medicated plaster for the topical treatment of post-herpetic neuralgia: results of a long-term study

OBJECTIVE

Evaluation of long-term efficacy and safety of the 5% lidocaine medicated plaster for neuropathic pain symptoms in patients with post-herpetic neuralgia (PHN).

MATERIALS AND METHODS

Design - a 12-month, open-label, phase III study with an open-label extension conducted at 34 outpatient clinics in 12 European countries. Patients - aged >or=50 years, newly recruited (average pain intensity >or=4) or pre-treated with the 5% lidocaine medicated plaster in a previous study. Interventions - application of up to three 5% lidocaine medicated plasters dependent upon size of the painful area for up to 12 hours per day. Outcome measures - efficacy measures included patients' recall of pain relief and pain intensity in the previous week. Adverse events (AEs) were also reported.

RESULTS

249 patients participated in the 12-month study, 247 were analysed (full analysis set, FAS). Newly recruited patients had a mean average pain intensity (11-point numerical rating scale [NRS]) of 5.9 +/- 1.4 at baseline, which decreased to 3.9 +/- 1.6 at week 12 and remained stable at 3.9 +/- 2.3 until the end of the 12-month study. In pre-treated patients, pain intensity decreased further from baseline (3.9 +/- 1.9) to study end (3.4 +/- 2.0). Pain relief values were consistent with pain intensity reductions and were sustained in patients continuing treatment in the extension phase (mainly >or=24 months treatment in total). The most common AEs tended to be infections such as bronchitis and nasopharyngitis. Forty-eight drug-related adverse events (DRAEs), mainly mild to moderate localised skin reactions, occurred in 31 (12.4%) patients in the first 12 months. The profile of DRAEs was similar in the extension phase.

CONCLUSIONS

This study suggests that long-term treatment with the 5% lidocaine medicated plaster may provide substantial and maintained reductions in pain intensity, and that it is continuously well tolerated in patients suffering from peripheral neuropathic pain associated with previous herpes zoster infection. These findings support the use of the 5% lidocaine medicated plaster as one of the first-line therapies in this population.

Topical glycopirrolate for the management of hyperhidrosis in herpetic neuralgia

Herpes zoster is a relapse of varicella. In certain cases, long-term pain and hyperhidrosis have been noted. Appearance of herpes zoster during pregnancy is infrequent. We described hyperhidrosis and pain treatment using glycopirrolate cream in a pregnant woman with herpetic neuralgia. A 32 year old woman, 21 weeks pregnant with second child, complained to her gynecologist of the appearance of a vesicular rash on the left half of the forehead that progressed toward her left eyelid, accompanied by lancinating pain, allodynia, hyperhidrosis and small edema, blepharitis and conjunctivitis. Following clinical and laboratory tests, she was diagnosed with herpes zoster ophtalmicus. Aciclovir therapy was administered 800 mg orally five times daily for seven days. Pain therapy was initiated with amitriptilline. We discontinued amitriptilline therapy after 10 days because of appearance of unwanted side effects. After skin changes ceased, we introduced Lidocaine patch into pain therapy which reduced the allodynia, but not the lancinating pain and hyperhidrosis. At that time we began using glycopirrolate cream which reduced pain intensity by 28.5% within 24 hours, and completely eliminated hyperhidrosis. After 48 hours of use, the pain completely disappeared. During the Glycopirrolate cream therapy, there were no side effects. This is a first report to document that a topical Glycopirrolate cream has a beneficial effect in a patient with hyperhidrosis and herpetic neuralgia.

Pregabalin for postherpetic neuralgia: placebo-controlled trial of fixed and flexible dosing regimens on allodynia and time to onset of pain relief

Time to onset of pain relief and improvement in allodynia in 269 patients with postherpetic neuralgia was examined in a 4-week randomized trial comparing flexibly dosed pregabalin (150-600 mg/d), fixed-dose pregabalin (300 mg/d), and placebo. For each patient with clinically meaningful pain reduction (>or=30%) at end point, onset of pain relief was defined as the first study day on which a patient reported >or=1-point reduction in pain relative to baseline. Average dose achieved was 396 mg/d in the flexible-dose group compared with 295 mg/d in the fixed-dose group. Median pain relief onset times were 3.5 days (flexible-dose), 1.5 days (fixed-dose), and >4 weeks (placebo). Compared with placebo, significantly more patients in both pregabalin treatment groups achieved >or=30% and >or=50% pain reduction at end point. Almost 95% of patients had brush-evoked allodynia, with 68% having moderate to severe allodynia (>or=40/100 mm). At baseline, pain and allodynia were highly correlated. Independent of treatment assignment, improvement in pain and improvement in allodynia were significantly correlated. Allodynia could serve as a useful surrogate outcome measure in future studies. Pregabalin was significantly better than placebo in alleviating allodynia (flexible-dose reduction, 26 mm; fixed-dose, 21 mm; placebo, 12 mm). Discontinuation rates due to adverse events were more frequent in the fixed-dose group.

PERSPECTIVE

A flexible-dose regimen reduces discontinuations, facilitates higher final doses, and results in a slightly greater pain relief. Allodynia (touch-evoked pain) can be of disabling severity and is present in nearly all patients with postherpetic neuralgia. Allodynia severity is correlated with pain severity and improvement in allodynia is correlated with clinical response.

Prevention of herpes zoster and its painful and debilitating complications

BACKGROUND

Reactivation of latent varicella-zoster virus in sensory neurons to cause herpes zoster (shingles) is common in adults 50 years of age and older; half of adults experience an episode by age 85 years. Herpes zoster is attributable to the progressive decline in the VZV-specific cell-mediated immunity that occurs with aging or other conditions that cause immune compromise. Herpes zoster and complications, such as postherpetic neuralgia (PHN), can have a substantial negative impact on quality of life.

DISCUSSION

The incidence of herpes zoster and its associated morbidity is increasing worldwide as the population ages. Nevertheless, the severity and impact of this condition, and its painful sequelae, are often unrecognized. Many patients delay seeking medical attention, complicating both diagnosis and treatment. Prevention appears to be the best option. A new herpes zoster vaccine significantly reduced the burden of illness (61.1%), the incidence of PHN (66.5%), and the incidence of herpes zoster (51.3%) (p < 0.001). Vaccine tolerability was good, with minor local injection site reactions the most common adverse event.

CONCLUSIONS

Herpes zoster and PHN represent a substantial burden in terms of suffering and associated costs. Immunization of older adults is a good option to prevent herpes zoster and PHN.

Segmental zoster paresis of limbs: report of three cases and review of literature

OBJECTIVES

Segmental zoster paresis is a relatively rare complication characterized by focal motor weakness, which may occur in limbs affected by herpes zoster. We demonstrate the clinical characteristics of segmental zoster paresis by reviewing the cases of 138 patients, including 3 of our patients.

CASE REPORT AND REVIEW SUMMARY

We report 3 patients with zoster paresis of the limbs. Patients 1 and 3 showed motor weakness in the left shoulder and arm after developing a herpetic rash in the left C5-C6 dermatomes. Patient 2 showed weakness in the right thigh and groin after a right L2-L3 herpetic eruption. The electromyograms of all 3 patients showed abnormal spontaneous activity in the affected muscles. Intravenous acyclovir and corticosteroid pulse therapy were added to oral antiviral drugs for patients 1 and 2. All 3 patients recovered favorably. Our review of the literature revealed that antiviral treatment may prevent the occurrence of zoster paresis; however, there is insufficient evidence to show what treatment hastens recovery from zoster paresis.

CONCLUSIONS

Segmental zoster paresis is still underrecognized by neurologists. Awareness of this disorder is important because it may eliminate unnecessary invasive investigations and lead to appropriate treatment. Further studies on the treatment are necessary.

An Integrative Approach for Treating Postherpetic Neuralgia?A Case Report

This report describes the successful treatment of a patient with postherpetic neuralgia using traditional pharmacology in combination with acupuncture.

CASE REPORT

A 13-year-old girl developed postherpetic neuralgia following a severe attack of varicella zoster. Despite a 1-week course of intravenous acyclovir initiated at the onset of symptoms, the patient developed persistent left facial pain and constant nausea after lesions were healed. A comprehensive pain treatment regimen, consisting of a stellate ganglia block, medications, transcutaneous electrical nerve stimulation and hypnosis, was administered, but the patient did not gain any incremental pain relief. The acupuncture service was consulted to provide assistance with this patient's pain management. A combination of body and auricular acupuncture as well as related techniques, including acupressure and transcutaneous acupoint electrical stimulation, was added to the pain treatment regimen. After 10 complementary acupuncture treatments over a 2-month period, the patient's nausea disappeared. Her left facial pain continued to decline from a maximum of 10 to 0 as assessed by a visual analog scale over a period of 4 months following self-administered treatments of acupressure and transcutaneous acupoint electrical stimulation. The patient was then gradually weaned off all her medications and the complementary acupuncture treatment. She was discharged from the pediatric pain clinic after 5 months of the combined therapy.

CONCLUSIONS

Acupuncture and its related techniques may be an effective adjunctive treatment for symptoms associated with postherpetic neuralgia and deserve further study.

Post-herpetic neuralgia in older adults: evidence-based approaches to clinical management

Many individuals across the globe have been exposed to the varicella-zoster virus (VZV) that causes chickenpox. After chickenpox has resolved, the virus remains latent in the dorsal root ganglia where it can re-emerge later in life as herpes zoster, otherwise known as shingles. Herpes zoster is a transient disease characterised by a dermatomal rash that is usually associated with significant pain. Post-herpetic neuralgia (PHN) is the term used for the condition that exists if the pain persists after the rash has resolved. Advanced age and compromised cell-mediated immunity are significant risk factors for reactivation of herpes zoster and the subsequent development of PHN. Though the pathophysiology of PHN is unclear, studies suggest peripheral and central demyelination as well as neuronal destruction are involved. Both the vaccine against VZV (Varivax) and the newly released vaccine against herpes zoster (Zostavax) may lead to substantial reductions in morbidity from herpes zoster and PHN. In addition, current evidence suggests that multiple medications are effective in reducing the pain associated with PHN. These include tricyclic antidepressants, antiepileptics, opioids, NMDA receptor antagonists as well as topical lidocaine (lignocaine) and capsaicin. Reasonable evidence supports the use of intrathecal corticosteroids, but the potential for neurological sequelae should prompt caution with their application. Epidural corticosteroids have not been shown to provide effective analgesia for PHN. Sympathetic blockade may assist in treating the pain of herpes zoster or PHN. For intractable PHN pain, practitioners have performed delicate surgeries and attempted novel therapies. Although such therapies may help reduce pain, they have been associated with disappointing results, with up to 50% of patients failing to receive acceptable pain relief. Hence, it is likely that the most effective future treatment for this disease will focus on prevention of VZV infection and immunisation against herpes zoster infection with a novel vaccine.

Safety and tolerability of a high-potency zoster vaccine in adults >/= 50 or years of age

BACKGROUND

Herpes zoster (HZ) incidence rises with age, especially after 50 years of age, probably due to waning varicella-zoster virus (VZV)-specific immunity. The Shingles Prevention Study [Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults, N Engl J Med 2005;352:2271-84], enrolled people >/= 60 or years of age and showed that zoster vaccine prevents HZ and postherpetic neuralgia (PHN), presumably through boosting VZV-specific immunity. This study of people >/= 50 or years of age compared the safety and tolerability of two zoster vaccine potencies.

METHODS

Adults >/= 50 or years old enrolled in a randomized, double-blind, multicenter study to compare the safety and tolerability of one dose of two zoster vaccine potencies, approximately 58,000 and approximately 207,000 plaque-forming units/dose. Adverse experiences (AEs) were recorded on a standardized Vaccination Report Card for 42 days postvaccination. For assessment of injection-site AEs, clinically acceptable tolerability was predefined based on experience with PNEUMOVAX 23, a licensed vaccine recommended for use in older people.

RESULTS

Six hundred and ninety-eight subjects (age 50-90 years, median 64 years) were enrolled. No serious vaccine-related AEs were reported. Similar AE rates were observed in the higher and lower potency groups (overall systemic AEs: 37.5 and 39.3%, vaccine-related systemic AEs: 10.9 and 13.2%, injection-site AEs: 63.0 and 59.8%). Rates for a combined endpoint of moderate or severe injection-site pain/tenderness/soreness and swelling were 17.2% (95% CI 13.9, 21.0) and 9.0% (95% CI 5.6, 13.4), respectively. Most combined endpoint events were reported as moderate in intensity.

CONCLUSIONS

Both vaccine potencies were generally well tolerated in this study of people > or years of age. Although rates of some moderate or severe injection-site AEs were greater in the higher potency group, all rates met the prespecified criteria for clinically acceptable tolerability.

Cutaneous Infections Associated with HIV/AIDS

With diminished and dysregulated cell-mediated immunity, HIV-infected individuals are susceptible to a myriad of skin infections. These infections include the conditions encountered in immunocompetent patients, as well as infections seen almost exclusively in the setting of HIV infection. The HIV/AIDS pandemic has made some previously rare infections more prominent. Although antiretroviral therapy has been helpful in relieving the burden of cutaneous infections in HIV-infected patients, it does not prevent all opportunistic infections in the skin and also has created new dilemmas.

Herpes zoster ophthalmicus in otherwise healthy children

PURPOSE

To evaluate the complications of herpes zoster ophthalmicus (HZO) in children.

DESIGN

Prospective-observational case series.

METHODS

Ten healthy patients (five boys, five girls) with HZO were prospectively followed. Data regarding best-corrected visual acuity, biomicroscopy, intraocular pressure, corneal sensitivity, and funduscopy were collected. The median duration of follow-up was 19 months (range eight to 78 months).

RESULTS

The mean age at presentation was 8.7 years (range two to 14 years +/-3.95). At last visit, two patients (20%) had decreased visual acuity and nine (90%) had some degree of abnormal corneal sensitivity and corneal opacity despite good final visual acuity.

CONCLUSION

In general, HZO seems to have a good prognosis in healthy children; nonetheless, some cases can present severe eye complications causing visual loss.

[A case of a second cancer of metachronous multiple primary non-small cell lung cancer successfully treated with TS-1 and CDDP chemotherapy]

The patient was a 66-year-old man who had undergone right upper lobectomy and ND 2a systematic lymph node dissection for lung cancer (M/D adenocarcinoma, p-stage IB) in March of 1999 . On November 2003, postoperative routine chest computed tomography(CT) demonstrated a mass in left S6, and pathological diagnosis revealed P/D squamous cell carcinoma (cT1N2M0, stage IIIA) by CT-guided needle biopsy and mediastinoscopy. At first, we tried two courses of a combination chemotherapy consisting of carboplatin (CBDCA) and paclitaxel every 3 weeks. After 2 courses, the regimen was stopped because of grade 3 arthritis. Then, two courses of CBDCA and gemcitabine were performed. The evaluation of the response was SD by the guidelines of Response Evaluation Criteria in Solid Tumor Groups. Next, gefitinib was orally administered for 6 months but the tumor and mediastinal lymph nodes were growing. In January 2005, oral administration of TS-1 (60 mg/1, 2 courses, 75 mg/3-6 courses) was begun twice a day for 21 consecutive days while cisplatin (60 mg/m(2)) was administered intravenously on day 8. The response was PR (the tumor decreased by 46%), no serious adverse effect was observed, and the patient maintained good quality of life throughout the chemotherapy. This case suggests that TS-1+CDDP chemotherapy may be an effective treatment in patients with advanced lung cancer even after many protocols of chemotherapy.

Oral health and morbidity--implications of oral infections on the elderly

Detrimental effects of oral infections on general health have been known for almost 3000 years. Modern studies, however, have cast new light on the pathogenic mechanisms by which oral infections appear to link with morbidity and mortality. In particular, among the elderly, poor dental health seems to associate with all-cause mortality. This review aims to provide an overview of present knowledge of these issues, starting from dental bacteraemia, oral mucosal infections and problems of drug resistance and, briefly, discussing what is known about the link between oral health and some systemic diseases such as atherosclerosis and type-2 diabetes. The main conclusions are that scientific evidence is still weak on these interactions and that the elderly should be better taken into account when planning future studies. Functions of the body differ in the frail and diseased from those of the young. Consequently, novel prevention and treatment strategies should be developed and properly tested for combating oral infections in elderly populations. Specific suggestions for further research are outlined.