Persons 50 years of age and older are not only at increased risk of developing herpes zoster, they are also more likely to suffer the long-term morbidity of postherpetic neuralgia (PHN). PHN is pain persisting after the rash of herpes zoster has healed. PHN affects at least 40% of all herpes zoster patients over age 50 and over 75% of herpes zoster patients over age 75; PHN is the single most common neurologic condition in elderly patients.
Objective:
The objective of this review is to evaluate interventions that may reduce or even eliminate PHN. No single therapy has been consistently effective for PHN. The most effective approach appears to be with the use of antiviral therapy early in the course of herpes zoster. The goals of ongoing studies in herpes zoster are to develop interventions that will further reduce the symptoms of PHN and/or to eliminate PHN by prophylaxis using the varicella vaccine.
Conclusions:
Reduction of PHN can best be achieved with the use of antiviral medication early in the course of herpes zoster; other classes of drugs are minimally effective in treating established PHN. Widespread use of the varicella vaccine may lead to secondary reductions in PHN in the distant future.
Get full access to this article
View all access options for this article.
References
1.
StrommenGLPucinoFTightRR. Human infection with herpes zoster: Etiology, pathophysiology, diagnosis, clinical course and treatment. Pharmacotherapy1988; 8:52–68.
2.
LoeserJD. Herpes zoster and postherpetic neuralgia. Pain1986; 25:149–164.
KostRGStrausSE. Postherpetic neuralgia—pathogenesis, treatment and prevention. N Engl J Med1996; 335:32–42.
7.
WatsonCPNTylerKLBickersDR. A randomized vehicle-controlled trial of topical capsaicin in the treatment of postherpetic neuralgia. Clin Ther1998; 15:510–526.
8.
GildenDH. Herpes zoster with postherpetic neuralgia—persisting pain and frustration. N Engl J Med1994; 330:932–934.
9.
LancasterTSilagyCGrayS. Primary care management of herpes zoster: Systematic review of evidence from randomized controlled trials. Br J Gen Pract1995; 45:39–45.
HessTMLutzLJNaussLA. Treatment of acute herpetic neuralgia. A case report and review of the literature. Minn Med1990; 73:37–10.
16.
MorrisGCGibsonSJHelmeRD. Capsaicin-induced flare and vasodilatation in patients with post-herpetic neuralgia. Pain1995; 63:93–101.
17.
DeBenedittisGLorenzettiA. Topical aspirin/diethyl ether mixture versus indomethacin and diclofenac/diethyl ether mixtures for acute herpetic neuralgia and postherpetic neuralgia: A double-blind crossover placebo-controlled study. Pain1996; 65:45–51.
RowbothamMCDaviesPSVerkempinckC. Lidocaine patch: Double-blind controlled study of a new treatment method for postherpetic neuralgia. Pain1996; 65:39–44.
20.
ChalkCHDyckPJ. Diseases of the peripheral nervous system. In: DaleDCFedermanDD, eds. Scientific American Medicine. New York: Scientific American Inc., 1998, vol 2, pp 1–15.
21.
WhitleyRJWeissHGnannJWJr. Acyclovir with and without prednisone for the treatment of herpes zoster: A randomized, placebo-controlled trial. Ann Intern Med1996; 125:376–383.
22.
ForrestJB. The response to epidural steroid injections in chronic dorsal root pain. Can Anaesth Soc J1980; 27:40–46.
23.
ErnstMESanteeJAKlepserTB. Oral corticosteroids for pain associated with herpes zoster. Ann Pharmacother1998; 32:1099–1103.
24.
KillianJMFrommGH. Carbamazepin in the treatment of neuralgia. Arch Neurol1968; 19:129–136.
25.
GildenDH. Acute viral central nervous system diseases. In: DaleDCFedermanDD, eds. Scientific American Medicine. New York: Scientific American Inc., 1998, vol 2, pp 1–9.
26.
BowsherD. Postherpetic neuralgia and its treatment: A retrospective survey of 191 patients. J Pain Symptom Manage1996; 12:290–299.
27.
RowbothamMHardenNStaceyB. Gabapentin for the treatment of postherpetic neuralgia. J Am Med Assoc1998; 280:1837–1842.
28.
GillinSSorkinLS. Gabapentin reverses the allodynia produced by the administration of anti-GD2 ganglioside, an immunotherapeutic drug. Anesth Analg1998; 86:111–116.
29.
HwangJHYakshTL. Effect of subarachnoid gabapentin on tactile-evoked allodynia in a surgically induced neuropathic pain model in the rat. Reg Anesth1997; 22:249–256.
30.
SinghLFieldMJFerrisP. The antiepileptic agent gabapentin (Neurontin) possesses anxiolytic-like and antinociceptive actions that are reversed by D-serine. Psychopharmacology1996; 127:1–9.
31.
XiaoW-HBennettGJ. Gabapentin has an antinociceptive effect mediated via a spinal site of action in a rat model of painful peripheral neuropathy. Pain1996; 2:267–273.
32.
BackonjaMBeydounAEdwardsKR. Gabapentin for the symptomatic treatment of painful neuropathy in patients with diabetes mellitus. J Am Med Assoc1998; 280:1831–1836.
33.
MellickGAMellicyLBMellickLB. Gabapentin in the management of reflex sympathetic dystrophy. J Pain Symptom Manage1995; 10:265–266.
34.
RosnerHRubinLKestenbaumA. Gabapentin adjunctive therapy in neuropathic pain states. Clin J Pain1996; 12:56–58.
35.
StaceyBROwenGTSinclairJD. Gabapentin for neuropathic pain states: A case series report (abstract). Ref Anesth1996; 21:865.
36.
RosenbergJMHarrellCRistieH. The effect of gabapentin on neuropathic pain. Clin J Pain1997; 13:251–255.
37.
AttalNParkerFBrasseurL. Efficacy of gabapentin on neuropathic pain: A pilot study. In: Program and abstracts of the 16th Annual Scientific Meeting of the American Pain Society, New Orleans, LA, October 23–26, 1997, Abstract 653.
38.
AbdiSLeeDHChungJM. The anti-allodynic effects of amitriptyline, gabapentin, and lidocaine in a rat model of neuropathic pain. Anesth Analg1998; 87:1360–1366.
39.
TaylorCPGeeNSSuTZ. A summary of mechanistic hypotheses of gabapentin pharmacology. Epilepsy Res1998; 29:233–249.
40.
WeltyDFSchielkeGPRothsteinJD. Potential treatment of amyotrophic lateral sclerosis with gabapentin: A hypothesis. Ann Pharmacother1995; 29:1164–1167.
41.
HuffJCBeanBBalfourHH. Therapy of herpes zoster with oral acyclovir. Am J Med1988; 85(suppl 2A):84–89.
42.
WoodMJOganPHMcKendrickMW. Efficacy of oral acyclovir treatment of acute herpes zoster. Am J Med1988; 85(suppl 2A):79–83.
43.
HuffJCDruckerJLClemmerA. Effect of oral acyclovir on pain resolution in herpes zoster: A reanalysis. J Med Virol Suppl1993; 1:93–96.
44.
CrooksRJFiddianAPJonesDA. Zoster-associated chronic pain: An overview of clinical trials with acyclovir. Scand J Infect Dis1991; 78:62–68.
45.
WoodMJKayRDworkinRH. Oral acyclovir accelerates pain resolution in herpes zoster: A meta-analysis of placebo-controlled trials. Clin Infect Dis1996; 22:341–347.
46.
TyringSBarbarashRANahlikJE. Famciclovir for the treatment of acute herpes zoster: Effects on acute disease and postherpetic neuralgia. Ann Intern Med1995; 123:89–96.
47.
DworkinRHBoonRJGriffinDRG. Postherpetic neuralgia: Impact of famciclovir, age, rash severity, and acute pain in herpes zoster patients. J Infect Dis1998; 178(suppl 1):S76–S80.
48.
SaltzamanRJurewiczRBoonR. Safety of famciclovir in patients with herpes zoster and genital herpes. Antimicrob Agents Chemother1994; 38:2454–2457.
49.
SullivanMSkiestDSignsD. Famciclovir in the management of acute herpes zoster in HIV+ patients [poster]. Presented at the Annual Meeting of the Infectious Diseases Society of America, Philadelphia, PA, October 25–28, 1998.
50.
TyringSBelangerRBezwodaW. Famciclovir treatment of herpes zoster in immunocompromised patients: A multicenter, double-blind, randomized, acyclovir-controlled trial. Cancer Invest2000; 19:13–22.
51.
BurnetteTCde MirandoP. Metabolic disposition of the acyclovir prodrug valacyclovir in the rat. Drug Metab Dispos1994; 22:60–64.
52.
De MirandoPBurnetteTC. Metabolic fate and pharmacokinetics of the acyclovir prodrug valaciclovir in cynomolgus monkeys. Drug Metab Dispos1994; 22:55–59.
53.
BeutnerKRFriedmanDJForszpaniakC. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother1995; 39:1546–1553.
54.
BeutnerKR. Antivirals in the treatment of pain. J Geriatr Dermatol1994; 6(2 suppl):23A–28A.
55.
DegreefH. Famciclovir Herpes Zoster Clinical Study Group. Famciclovir, a new oral antiherpes drug: Results of the first controlled clinical study demonstrating its efficacy and safety in the treatment of uncomplicated herpes zoster in immunocompetent patients. Int J Antimicrob Agents1994; 4:241–246.
56.
WoodMJJohnsonRWMcKendrickMW. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med1994; 330:896–900.
57.
BowsherD. The effects of preemptive treatment of postherpetic neuralgia with amitriptyline: A randomized, double-blind, placebo-controlled trial. J Pain Symptom Manage1997; 13:327–331.
58.
DworkinRH. Prevention of postherpetic neuralgia. Lancet1999; 353:1636–1637.
59.
HoughtonAKLuYWestlundKN. S-(+)-isobutylgaba and its steroisomer reduces the amount of inflammation and hyperalgesia in an acute arthritis model in the rat. J Pharmacol Exp Ther1998; 285:533–538.
60.
LuYWestlundKN. Gabapentin attenuates nociceptive behaviors in an acute arthritis model in rats. J Pharmacol Exp Ther1999; 290:214–219.
61.
KingeryWS. A critical review of controlled clinical trials for peripheral neuropathic pain and complex regional pain syndromes. Pain1997; 73:123–139.
62.
CesenaRMCalcuttNA. Gabapentin prevents hyperalgesia during the formalin test in diabetic rats. Neurosci Lett1999; 262:101–104.
63.
FieldMJMcClearySHughesJ. Gabapentin and pregabalin, but not morphine and amitriptyline, block both static and dynamic components of mechanical allodynia induced by streptozocin in the rat. Pain1999; 80:391–398.
64.
GurneyMECuttingFBZhaiP. Benefit of vitamin E, riluzole and gabapentin in a transgenic model of familial amyotrophic lateral sclerosis. Ann Neurol1996; 39:147–157.
