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Herpes zoster

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Herpes zoster is "an acute infectious, usually self-limited, disease believed to represent activation of latent varicella-zoster virus in those who have been rendered partially immune after a previous attack of Chickenpox. It involves the sensory ganglia and their areas of innervation and is characterized by severe neuralgic pain along the distribution of the affected nerve and crops of clustered vesicles over the area."[1]

Epidemiology

For adults over 60 years of age, the incidence is about 1% per year.[2]

Prevention

The Centers for Disease Control recommends the zoster vaccination (Zostavax - which is different than the pediatric vaccine Variva) for adults aged at least 60 years:[3] Contraindications include:[4]

  • allergic to neomycin, or any component of the vaccine
  • immuncompromise due to radiation, corticosteroids, or conditions such as AIDS and cancers.
  • pregnancy
  • people who are in close contact with pregnant women who have not had chickenpox probably not have vaccine

A randomized controlled trial of a vaccine for adults aged at least 60 years reduced the incidence of zoster over three years by about one-half - from a rate of 3.3% down to 1.6%; approximately 60 people would have to take the vaccine to prevent one case of shingles (number needed to treat=59).[5] A more recent cohort study in a community setting estimated similar effect.[6]

In the United States, the vaccine is more expensive than many other vaccines, and its cost may be a factor with some third-party payors, or with the target older population of limited income. Some public health programs, however, are aggressive at providing it to that target group.

Treatment

Combining antiviral agents with a corticosteroid may reduce the incidence of postherpetic neuralgia.[7][8]

Early tricyclic antidepressant[9] or gabapentin[10] may help.

Postherpetic neuralgia

While the acute phase is uncomfortable, the greatest concern is that some patients may develop postherpetic neuralgia. If postherpetic neuralgia develops, there are a number of therapies. Comparative studies suggest that tricyclic antidepressants such as desipramine[11] and opioid analgesics such as oxycodone[12] are more effective than anticonvulsants such as gabapentin and pregabalin. Other options include topical lidocaine[13] and topical capsaicin.

These therapies are not mutually exclusive. A clinician may choose, for example, to use an anticonvulsant or antidepressant in combination with opioid analgesics.

References

  1. National Library of Medicine. Herpes Zoster. Retrieved on 2007-11-02.
  2. Yawn BP, Saddier P, Wollan PC, St Sauver JL, Kurland MJ, Sy LS (2007). "A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction". Mayo Clin. Proc. 82 (11): 1341–9. PMID 17976353[e]
  3. Centers for Disease Control and Prevention (2006). CDC Media Relations Press Release - October 26, 2006. Retrieved on 2007-10-22.
  4. Centers for Disease Control and Prevention (2006). CBER - Zoster Vaccine, Live, (Oka/Merck), Zostavax Questions & Answers. Retrieved on 2007-10-22.
  5. Oxman MN, Levin MJ, Johnson GR, et al (2005). "A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults". N. Engl. J. Med. 352 (22): 2271–84. DOI:10.1056/NEJMoa051016. PMID 15930418. Research Blogging.
  6. Tseng HF, Smith N, Harpaz R, Bialek SR, Sy LS, Jacobsen SJ (2011). "Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease.". JAMA 305 (2): 160-6. DOI:10.1001/jama.2010.1983. PMID 21224457. Research Blogging.
  7. Whitley RJ, Weiss H, Gnann JW, Tyring S, Mertz GJ, Pappas PG et al. (1996). "Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group.". Ann Intern Med 125 (5): 376-83. PMID 8702088[e]
  8. High, Kevin (30 September 2005), "Reducing the Public Health Burden of Herpes Zoster and Postherpetic Neuralgia", Medscape CME
  9. Bowsher D (1997). "The effects of pre-emptive treatment of postherpetic neuralgia with amitriptyline: a randomized, double-blind, placebo-controlled trial.". J Pain Symptom Manage 13 (6): 327-31. PMID 9204652[e]
  10. Berry JD, Petersen KL (2005). "A single dose of gabapentin reduces acute pain and allodynia in patients with herpes zoster.". Neurology 65 (3): 444-7. DOI:10.1212/01.wnl.0000168259.94991.8a. PMID 16087911. Research Blogging.
  11. O'Connor AB, Noyes K, Holloway RG (2007), "A Cost-Effectiveness Comparison of Desipramine, Gabapentin, and Pregabalin for Treating Postherpetic Neuralgia", Journal of the American Geriatrics Society 55 (8) pp. 1176-1184
  12. Dworkin RH, Barbano RL, Tyring SK, et al (April 2009). "A randomized, placebo-controlled trial of oxycodone and of gabapentin for acute pain in herpes zoster". Pain 142 (3): 209–17. DOI:10.1016/j.pain.2008.12.022. PMID 19195785. Research Blogging.
  13. Kanai A, Kumaki C, Niki Y, Suzuki A, Tazawa T, Okamoto H (2009 Jul-Aug). "Efficacy of a metered-dose 8% lidocaine pump spray for patients with post-herpetic neuralgia.". Pain Med 10 (5): 902-9. DOI:10.1111/j.1526-4637.2009.00662.x. PMID 19682274. Research Blogging.