Herpes : the journal of the IHMF
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Varicella zoster virus (VZV) outbreak is a significant cause of morbidity in patients suffering from blood-related malignancies, occurring mostly among those affected by lymphoproliferative disorders and in those receiving haematopoietic stem-cell transplantation. The elucidated pathological mechanisms of VZV-related painful complications have provided the rationale for acute zoster pain (AZP) and post-herpetic neuralgia (PHN) treatment with antiviral therapy combined with neuroactive agents, such as tricyclic or anticonvulsant agents. ⋯ We successfully treated (with oxycodone) 12 consecutive patients suffering from AZP and long-lasting PHN resistant to several agents, including anticonvulsants and analgesics. Our experience is reported together with a brief overview of the management of these often distressing and intractable complications.
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Herpes zoster is a common condition that can have a significant impact on quality of life among older adults. A significant proportion of older subjects with herpes zoster develop post-herpetic neuralgia (PHN), a chronic condition that is difficult to treat. The Shingles Prevention Study was a large-scale clinical trial to determine the efficacy of a live, attenuated varicella zoster virus (VZV) vaccine ('zoster vaccine') for preventing or attenuating herpes zoster in subjects aged > or =60 years. ⋯ VZV-specific cell-mediated immunity (CMI) was boosted significantly by the zoster vaccine. This boost remained substantially intact for the 3 years of follow-up. It is likely that the vaccine-induced boost in VZV-specific CMI reversed the natural decline in these responses that occurs as part of the ageing process, thereby protecting vaccine recipients against herpes zoster and its complications.
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Herpes zoster episodes commence with a prodromal period of about 4 days with symptoms including pain and malaise. This is followed by a rash lasting approximately 2-4 weeks, with possible subacute herpetic neuralgia for up to 3 months, followed, in some patients, by a period of post-herpetic neuralgia (PHN) lasting months or possibly years. Severe acute pain is more likely in older females and those with a prodrome or severe rash. ⋯ Treatments for acute herpes zoster and PHN include established antivirals, alone or in combination with steroids, analgesics and neural blockade with local anaesthetics. Commonly used pain relief includes acetaminophen/paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, tricyclic antidepressants, gabapentin, pregabalin and topical analgesics. Effective and long-lasting pain relief in herpes zoster and PHN remains a largely unmet medical need.
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Following the development of a herpes zoster vaccine and the successful introduction of widespread varicella vaccination in the USA, many countries are considering similar vaccination programmes. However, before implementing such programmes, it is important to describe the regional baselines of varicella and herpes zoster epidemiology, both to aid the design of vaccination strategies and to observe trends after the introduction of vaccination. In many areas of the world, this information is difficult to gather, and the epidemiology of herpes zoster and post-herpetic neuralgia in these regions is poorly understood. ⋯ Unexpectedly for tropical countries, the incidences of herpes zoster in Asia and South America also appear to be comparable with those in Europe and the USA, despite the delayed acquisition of varicella-zoster virus infection in Asia. In Brazil, there is some evidence for higher than expected incidence rates for herpes zoster in young adults. The epidemiology of herpes zoster in Asia and South America suggests that recommendations on treatment and prevention from Europe and the USA may be relevant to these countries.