Masih terkait artikel Varicella sebelumnya, berikut saya sertakan referensi untuk Herpes Zoster dan Postherpetic Neuralgia atau lazim disebut Nyeri pasca serangan herpes zoster.
Herpes Zoster
Pathophysiology
Reactivation of latent virus from dorsal root ganglion. Inflammation to acute viral ID in segmental nerve. Contagious to non-immune persons, Avoid contact until rash heals
Symptoms
Pain within dermatome occurs first
Rash develops after 48-72 hours
Starts as erythematous rash
Clear Vesicles then develop
Prodrome may be present
Fever
Chills
Malaise
Signs
Rash
Erythematous base
Clear Vesicles
Tender regional lymph nodes
Labs
Tzanck Smear of lesion base
Multinucleated giant cells
Viral antigen detection
Serologic titers to Herpes Zoster
Rash
Erythematous base
Clear Vesicles
Tender regional lymph nodes
Labs
Tzanck Smear of lesion base
Multinucleated giant cells
Viral antigen detection
Serologic titers to Herpes Zoster
Complications
Postherpetic Neuralgia
Meningitis
Encephalitis
Granulomatous Angiitis with contralateral Hemiplegia
Cutaneous dissemination in Lymphoma (40%)
Postherpetic Neuralgia
Meningitis
Encephalitis
Granulomatous Angiitis with contralateral Hemiplegia
Cutaneous dissemination in Lymphoma (40%)
Management: General
Relative indications for antivirals (maximal benefit)
Onset within 72 hours of starting treatment
Age 50 years and older
More than 50 lesions
Oral antiviral agents
Acyclovir 800 mg PO 5x/day for 7 days
Reduces healing time, pain, and rash dissemination
Valacyclovir appeared more effective in over age 50
(1999) Med Lett Drugs Ther 41:113
Valacyclovir 1 g PO tid for 7 days
Equivalent efficacy to Famciclovir
Tyring (2000) Arch Fam Med 9:863
Famciclovir 500 mg PO tid for 7 days
Lesions healed faster, more brief virus shedding
Reduces Postherpetic Neuralgia duration by 2 months
Reference
Tyring (1995) Ann Intern Med 123:89
Relative indications for antivirals (maximal benefit)
Onset within 72 hours of starting treatment
Age 50 years and older
More than 50 lesions
Oral antiviral agents
Acyclovir 800 mg PO 5x/day for 7 days
Reduces healing time, pain, and rash dissemination
Valacyclovir appeared more effective in over age 50
(1999) Med Lett Drugs Ther 41:113
Valacyclovir 1 g PO tid for 7 days
Equivalent efficacy to Famciclovir
Tyring (2000) Arch Fam Med 9:863
Famciclovir 500 mg PO tid for 7 days
Lesions healed faster, more brief virus shedding
Reduces Postherpetic Neuralgia duration by 2 months
Reference
Tyring (1995) Ann Intern Med 123:89
Systemic Corticosteroids
Use is controversial
May be associated with increased complications
May reduce acute pain and speed up healing
Does not reduce risk of Postherpetic Neuralgia
Wood (1994) N Engl J Med 330:896
Use is controversial
May be associated with increased complications
May reduce acute pain and speed up healing
Does not reduce risk of Postherpetic Neuralgia
Wood (1994) N Engl J Med 330:896
Management: Special Circumstances
Zoster Ophthalmicus
Atropine
Topical Antiviral (IUDR, ara-A, Acyclovir)
Analgesic
Immunocompromised Patient
Acyclovir 10 mg/kg IV q8h 10 days
Zoster Ophthalmicus
Atropine
Topical Antiviral (IUDR, ara-A, Acyclovir)
Analgesic
Immunocompromised Patient
Acyclovir 10 mg/kg IV q8h 10 days
Prophylaxis: Varicella Immune Globulin (VZIG) Indications
Immunodeficient under age 15 years
Give within 72-96 hours exposure
Newborn of infected mother
Exposure 5 days before delivery or 2 days after
Immunodeficient under age 15 years
Give within 72-96 hours exposure
Newborn of infected mother
Exposure 5 days before delivery or 2 days after
Prevention
Avoid contact with active shingles or Chicken Pox
Consider prophylaxis if exposure in high-risk groups
Varicella Vaccine
May reduce risk of developing shingles
Now part of routine Primary Series
Booster Varivax for age >55 years may be considered
Avoid contact with active shingles or Chicken Pox
Consider prophylaxis if exposure in high-risk groups
Varicella Vaccine
May reduce risk of developing shingles
Now part of routine Primary Series
Booster Varivax for age >55 years may be considered
Post Herpetic Neuralgia
Symptoms
Persistent pain in dermatomal distribution
Persistent pain in dermatomal distribution
Management: Topical
Lidocaine 5% ointment (Xylocaine)
Apply to affected area every 4-12 hours prn
Capsaicin cream (Zostrix) 0.025% to 0.075%
Apply to affected area three to five times daily
Lidocaine 5% ointment (Xylocaine)
Apply to affected area every 4-12 hours prn
Capsaicin cream (Zostrix) 0.025% to 0.075%
Apply to affected area three to five times daily
Management: Anti-depressants
General
Amitriptyline more effective than Gabapentin
Adverse effects significantly limit this class
Many physicians recommend start with Gabapentin trial
Gnann (2002) N Engl J Med 347:340
Tricyclic Antidepressants
Agents
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Imipramine (Tofranil)
Desipramine (Norpramin)
Efficacy
As effective and better tolerated than Narcotics
Raja (2002) Neurology 59:1015
Other anti-depressants
Maprotiline (Ludiomil)
Sertraline (Zoloft)
General
Amitriptyline more effective than Gabapentin
Adverse effects significantly limit this class
Many physicians recommend start with Gabapentin trial
Gnann (2002) N Engl J Med 347:340
Tricyclic Antidepressants
Agents
Amitriptyline (Elavil)
Nortriptyline (Pamelor)
Imipramine (Tofranil)
Desipramine (Norpramin)
Efficacy
As effective and better tolerated than Narcotics
Raja (2002) Neurology 59:1015
Other anti-depressants
Maprotiline (Ludiomil)
Sertraline (Zoloft)
Management: Refractory Postherpetic Neuralgia
See also Chronic Pain Management
Transcutaneous Electric Nerve Stimulation (TENS)
Biofeedback
Nerve Block
Intrathecal Methylprednisolone 60 mg at L2-L3
Good to excellent pain relief in refractory cases
Relief persists longer than 2 years
See also Chronic Pain Management
Transcutaneous Electric Nerve Stimulation (TENS)
Biofeedback
Nerve Block
Intrathecal Methylprednisolone 60 mg at L2-L3
Good to excellent pain relief in refractory cases
Relief persists longer than 2 years
