Herpes Zoster

Herpes Zoster and Post Herpes Zoster and Post herpetic Neuralgia:herpetic Neuralgia:

Evidenced based guidelines for Evidenced based guidelines for the Gerontological Nurse the Gerontological Nurse

Practioner.Practioner.

Tracy Ann Ramos BS , R N.Tracy Ann Ramos BS , R N.

April 6, 2006April 6, 2006

Presentation Objectives.Presentation Objectives. Identify the risk factors and clinical manifestations of herpes Identify the risk factors and clinical manifestations of herpes

zoster and potential complications in the older adult.zoster and potential complications in the older adult.

Briefly review the epidemiology, Pathophysiology and Briefly review the epidemiology, Pathophysiology and diagnoses of herpes zoster and its complications.diagnoses of herpes zoster and its complications.

Recognize the burden of illness of herpes zoster through Recognize the burden of illness of herpes zoster through discussion of recent research findings and clinical data.discussion of recent research findings and clinical data.

Articulate evidence based therapeutic solutions, (Non- Articulate evidence based therapeutic solutions, (Non- pharmacological, pharmacological and complimentary pharmacological, pharmacological and complimentary therapies) to the management of post-herpetic neuralgia there therapies) to the management of post-herpetic neuralgia there by improving the quality of life of the older adult. by improving the quality of life of the older adult.

Discuss the implications of the GNP role in the management Discuss the implications of the GNP role in the management and future research of post-hepatic neuralgia. and future research of post-hepatic neuralgia.

Role and responsibilities of the Role and responsibilities of the GNP in the treatment of Herpes GNP in the treatment of Herpes

zoster and PHNzoster and PHN..• Assisting the older adult to function at his Assisting the older adult to function at his

or hers highest level.or hers highest level.• Assisting the older adult in minimizing Assisting the older adult in minimizing

health risks.health risks.• Providing information, education and Providing information, education and

resources to older adults.resources to older adults.• Recognizing and addressing the frequently Recognizing and addressing the frequently

atypical response of older adults to disease atypical response of older adults to disease and its treatments.and its treatments.

Scope and Standards of Gerontological Nursing (2002)Scope and Standards of Gerontological Nursing (2002)

Role and responsibilities of the Role and responsibilities of the GNP in the treatment of GNP in the treatment of Herpes Zoster and PHN.Herpes Zoster and PHN.• Assessment, treatment and evaluation methodology based on evidenced based practice.Assessment, treatment and evaluation methodology based on evidenced based practice.

• Collaboration with the older adult, caregiver and all members of the healthcare team to Collaboration with the older adult, caregiver and all members of the healthcare team to provide comprehensive care.provide comprehensive care.

• Provide guidance and care to the older adult that respects human dignity and the Provide guidance and care to the older adult that respects human dignity and the uniqueness of the individual.uniqueness of the individual.

• Considers factors related to safety ,effectiveness and cost in planning and delivering Considers factors related to safety ,effectiveness and cost in planning and delivering patient care. patient care.



DefinitionsDefinitionsHerpes Zoster:Herpes Zoster:• Acute, localized infection of the Varicella-Zoster virus, Acute, localized infection of the Varicella-Zoster virus,

which causes a painful blistering, pruritic rash.which causes a painful blistering, pruritic rash.

Post-Herpetic NeuralgiaPost-Herpetic Neuralgia::• Pain that persists for more than 1 month after the Pain that persists for more than 1 month after the

onset of Herpes zoster.onset of Herpes zoster.

U.S Library of medicine 2006, Journal of Family U.S Library of medicine 2006, Journal of Family practice(2003)practice(2003)

Historical PerspectiveHistorical Perspective The Varicella-Zoster Virus is estimated to have The Varicella-Zoster Virus is estimated to have

been around 70 million years. been around 70 million years. Initially named by Hippocrates; Initially named by Hippocrates; herpes=to creep, Zoster = girdle (Greek)herpes=to creep, Zoster = girdle (Greek) Shingles = belt, (Latin).Shingles = belt, (Latin). Not until 1940 was the etiology of the virus Not until 1940 was the etiology of the virus

established.established. VZV was finally isolated in 1952 by a Harvard VZV was finally isolated in 1952 by a Harvard

Microbiologist.Microbiologist. Finally sequenced in 1986. Finally sequenced in 1986.

Archives of Neurology Archives of Neurology ( 2004)( 2004)

Question ?Question ?

In view of the Varicella vaccine In view of the Varicella vaccine introduced in 1995 for children, introduced in 1995 for children, should we see more or less Herpes should we see more or less Herpes Zoster in the future ?Zoster in the future ?

Epidemiology/ EtiologyEpidemiology/ Etiology• Estimated 1 million cases in the U.S each year.Estimated 1 million cases in the U.S each year.• Incidence increases with age and is expected to rise in the future due to reduced Incidence increases with age and is expected to rise in the future due to reduced

exposure to Varicella.exposure to Varicella.• The childhood Varicella vaccine may The childhood Varicella vaccine may ultimatelyultimately reduce the incidence of Herpes reduce the incidence of Herpes

Zoster.Zoster.• Rarely seen < 50 years of age.Rarely seen < 50 years of age.• 30% of previously immune persons > 60yrs have no detectable antibodies. VZV is a 30% of previously immune persons > 60yrs have no detectable antibodies. VZV is a

DNA virus, it is a neurocutaneous viral infection and a member of the herpes group.DNA virus, it is a neurocutaneous viral infection and a member of the herpes group.• Recurrence of HZ is rare, unless immune-compromised, may be mistaken for herpes Recurrence of HZ is rare, unless immune-compromised, may be mistaken for herpes

simplex.simplex.

Journal of family practice(2003), BMJ (2003)Journal of family practice(2003), BMJ (2003)

Epidemiology/ EtiologyEpidemiology/ Etiology• Following primary infection of the virus (Varicella -chicken pox), it Following primary infection of the virus (Varicella -chicken pox), it

lies dormant until reactivated in later life. (Herpes Zoster-lies dormant until reactivated in later life. (Herpes Zoster-shingles)shingles)

• The virus lies dormant in the sensory nerve ganglia, dorsal root The virus lies dormant in the sensory nerve ganglia, dorsal root and cranial nerve ganglia.and cranial nerve ganglia.

• Reactivation of the virus is linked to a reduction of cell mediated Reactivation of the virus is linked to a reduction of cell mediated immunity. (Age, immuno-compromised)immunity. (Age, immuno-compromised)

• Generally involves the skin of a single dermatome Generally involves the skin of a single dermatome • 15-35% of patients with Herpes Zoster will develop PHN15-35% of patients with Herpes Zoster will develop PHN• African Americans are 1/4th as likely to developAfrican Americans are 1/4th as likely to develop Herpes Herpes Zoster Zoster PoPostgraduate medicine (2005),Journal of pain(2005stgraduate medicine (2005),Journal of pain(2005) ) . . Management guidelines for NPs working with older adults.(FADavis,2004)Management guidelines for NPs working with older adults.(FADavis,2004)

Pathophysiology of Pathophysiology of Herpes ZosterHerpes Zoster

• Reactivation can occur in the presence of stress, surgery, or Reactivation can occur in the presence of stress, surgery, or injury. injury.

• Following reactivation the virus travels at a possible rate of Following reactivation the virus travels at a possible rate of 1.7-10mm per hour. Estimated time for the virus to leave the 1.7-10mm per hour. Estimated time for the virus to leave the ganglion and reach the peripheral nerve and the development ganglion and reach the peripheral nerve and the development of cutaneous vesicles is 48-96 hours.of cutaneous vesicles is 48-96 hours.

• Hemorrhagic inflammation is characterized at the cellular Hemorrhagic inflammation is characterized at the cellular level.level.

• Fibrosis is noted at the dorsal root ganglion, nerve root and Fibrosis is noted at the dorsal root ganglion, nerve root and peripheral nerve upon resolution of the acute stage.peripheral nerve upon resolution of the acute stage.

The journal of Urology (2003)The journal of Urology (2003)

Risk Factors for PHNRisk Factors for PHNReplicated risk factorsReplicated risk factors..• Older ageOlder age• Greater acute painGreater acute pain• Severity of rashSeverity of rash• History of a prodrome.History of a prodrome.

Less well replicated risk factors.Less well replicated risk factors.• Female genderFemale gender• Greater sensory abnormalities in the affected dermatomeGreater sensory abnormalities in the affected dermatome• Polyneuropathy,brainstem and cervical cord Polyneuropathy,brainstem and cervical cord

abnormalities.abnormalities.• Psychosocial variablesPsychosocial variables

Lancet(2006) Journal of pain(2005)Lancet(2006) Journal of pain(2005)

Clinical Manifestations of Clinical Manifestations of Herpes zoster.Herpes zoster.

Prodrome symptoms may include chills, fever, Prodrome symptoms may include chills, fever, malaise, G.I. disturbance and parasthesia or malaise, G.I. disturbance and parasthesia or neuralgia along the affected dermatome.neuralgia along the affected dermatome.

Red papules usually appear along the affected Red papules usually appear along the affected dermatome within 3 days.( usually last for <day)dermatome within 3 days.( usually last for <day)

The eruption of vesicles closely follows the The eruption of vesicles closely follows the maculopapular rash.maculopapular rash.

Vesicles are fluid filled and can transmit the Vesicles are fluid filled and can transmit the virus, usually dry up in an average of 7 days.virus, usually dry up in an average of 7 days.

Scarring may occur at the site.Scarring may occur at the site. Mahan&Buttarro 2006, Merck manual of Mahan&Buttarro 2006, Merck manual of

geriatrics (2000)geriatrics (2000)

Clinical Manifestations of Clinical Manifestations of Herpes zoster.Herpes zoster.

Distribution: 50-60% Thoracic, 10-20%Trigeminal, 10-20%Cervical, 5-Distribution: 50-60% Thoracic, 10-20%Trigeminal, 10-20%Cervical, 5-10% Lumbar, and <5% Sacral.10% Lumbar, and <5% Sacral.

99% of all cases are unilateral and do not cross the midline unless 99% of all cases are unilateral and do not cross the midline unless there is > one dermatome affected or dissemination has occurred. there is > one dermatome affected or dissemination has occurred. (immune-compromised)(immune-compromised)

Neuropathic pain may precede the onset of the rash or develop Neuropathic pain may precede the onset of the rash or develop simultaneously . (Acute herpetic neuralgia)simultaneously . (Acute herpetic neuralgia)

Without complications HZ typically lasts 2-4 weeks.Without complications HZ typically lasts 2-4 weeks.

NLM (2006) Mahan & Buttaro 2006, Merck manual of geriatrics (2000)NLM (2006) Mahan & Buttaro 2006, Merck manual of geriatrics (2000)

Merck Manual of geriatrics(2000)Merck Manual of geriatrics(2000)

Herpes vesiclesHerpes vesicles

Ophthalmic Herpes Ophthalmic Herpes zosterzoster

Hutchinson signHutchinson sign

Ramsey Hunt syndromeRamsey Hunt syndrome


What would you say the burden of What would you say the burden of illness is on the elderly given the illness is on the elderly given the clinical manifestations ?clinical manifestations ?

Burden of illnessBurden of illnessA cross sectional survey performed on 84 patients with PHN in A cross sectional survey performed on 84 patients with PHN in

6 European countries.- Results:6 European countries.- Results:

• Developed sleep disorder.Developed sleep disorder.• AnxietyAnxiety• DepressionDepression• Decreased walking ability (depending on Decreased walking ability (depending on

dermatome)dermatome)• Withdrawal from relationships / activities.Withdrawal from relationships / activities.• Reduction in the general enjoyment of life.Reduction in the general enjoyment of life.

Age and aging, Oxford University,U.K Age and aging, Oxford University,U.K (2006)(2006)


What could be the differential What could be the differential diagnoses given these symptoms ?diagnoses given these symptoms ?

Differential Diagnoses of Differential Diagnoses of Herpes ZosterHerpes Zoster

• Herniated disc.Herniated disc.• M IM I• Acute abdomenAcute abdomen• Musculoskeletal disorder.Musculoskeletal disorder.• PleurisyPleurisy• Migraine headache / Temporal artritis, Trigeminal Migraine headache / Temporal artritis, Trigeminal

neuralgia.neuralgia.• PolymyalgiaPolymyalgia rheumaticarheumatica

Merck Merck

Manual of Geriatrics (2000)/postgrad medicine (2005)Manual of Geriatrics (2000)/postgrad medicine (2005)

Complications of Herpes Complications of Herpes ZosterZoster

• Bacterial infection of the skin.-requires ABTBacterial infection of the skin.-requires ABT• Corneal scarring /vision loss/conjunctivitis-Corneal scarring /vision loss/conjunctivitis-

immediate referral if eyes are involved.immediate referral if eyes are involved.• EncephalitisEncephalitis• Guillain- Barre Syndrome.Guillain- Barre Syndrome.• Urinary retention.Urinary retention.• Bells Palsy ( Zoster sine herpetic )Bells Palsy ( Zoster sine herpetic )• Cochlear vesicular involvement (Ramsey hunt Cochlear vesicular involvement (Ramsey hunt

syndrome)syndrome)• Loss of tasteLoss of taste Merck Manual of Geriatrics(2000)BMj 2004Merck Manual of Geriatrics(2000)BMj 2004

Clinical Presentation of Clinical Presentation of PHNPHN

• Pain that persists for more than a month following Pain that persists for more than a month following the onset of Herpes Zoster.the onset of Herpes Zoster.

• Pain may last months or in a few cases over a year.Pain may last months or in a few cases over a year.• Pain is described as lacinating, burning, shooting, Pain is described as lacinating, burning, shooting,

stabbing, paroxysmal or electrical.stabbing, paroxysmal or electrical.• Allodynia occurs.( pain in reaction to a non- Allodynia occurs.( pain in reaction to a non-

noxious stimulai,light touch, clothing).noxious stimulai,light touch, clothing).• Pain can be debilitating and interfere with daily Pain can be debilitating and interfere with daily

functioning .functioning .• Pain ↑ through out the dayPain ↑ through out the day• Pain has 2 components : 1) Central , 2) Peripheral.Pain has 2 components : 1) Central , 2) Peripheral. JAMA (2005), Pain (2006)JAMA (2005), Pain (2006)

Question?Question?

What questions would you ask in What questions would you ask in the History/R.O.S, in relation to the History/R.O.S, in relation to Herpes Zoster/PHN ? Herpes Zoster/PHN ?

Patient history/ROSPatient history/ROS• PMH : Chicken pox, recent contacts, recent surgeries,current/ PMH : Chicken pox, recent contacts, recent surgeries,current/

ongoing therapies, recent illness. Comorbidities.ongoing therapies, recent illness. Comorbidities.• Social/History : Stress, lifestyle habits, support Social/History : Stress, lifestyle habits, support

system/caregivers.system/caregivers.• Current state of health : Pain, (Old CART).? Dermatome,. Ask Current state of health : Pain, (Old CART).? Dermatome,. Ask

questions pertaining to rash.questions pertaining to rash.• ? Allodynia (sensitive to fine touch), ? Hyperalgesia (abnormally ? Allodynia (sensitive to fine touch), ? Hyperalgesia (abnormally

low sensitivity to pain), ? Dysethesia (pins and needles, worms) .low sensitivity to pain), ? Dysethesia (pins and needles, worms) .• Ask questions pertinent to particular dermatome involved.Ask questions pertinent to particular dermatome involved.• Activities of daily living/quality of life. Activities of daily living/quality of life. • Rule out differential diagnoses.Rule out differential diagnoses. Journal of pain(2004) Journal of pain(2004)

Anesthesia &Analgesia (2003)Anesthesia &Analgesia (2003)


What parts of the physical exam What parts of the physical exam will you perform ?will you perform ?

Physical ExaminationPhysical Examination

• General survey.General survey.• Skin inspection. Skin inspection. • Inspection of the rash if present.Inspection of the rash if present.• Location of dermatome, (exam system above and Location of dermatome, (exam system above and

below)below)• Neurological assessment of the affected Neurological assessment of the affected

dermatome. (vibration sense)dermatome. (vibration sense)• Test for allodynia using cotton wool balls and sharp Test for allodynia using cotton wool balls and sharp

object.object.• Adapt you assessment to the cognitively impaired Adapt you assessment to the cognitively impaired

personperson

Diagnostic CriteriaDiagnostic CriteriaDiagnoses of Herpes Zoster / PHN is Diagnoses of Herpes Zoster / PHN is

primarily clinical presentation: primarily clinical presentation: (May be all or (May be all or some of the following)some of the following)

• History of chicken pox in younger yearsHistory of chicken pox in younger years• Presence of prodromal symptomsPresence of prodromal symptoms• Possible eruption of Maculopapular / vesicular Possible eruption of Maculopapular / vesicular

rash.rash.• Neuropathic pain that follows the dermatomal Neuropathic pain that follows the dermatomal

path. path. • Possible presence of either or all : Possible presence of either or all : Allodynia , Allodynia ,

Hyperalgesia, Dysethesia.Hyperalgesia, Dysethesia.• Positive PCRPositive PCR CDC guidelines 2005,Merck Manual 2000CDC guidelines 2005,Merck Manual 2000

Laboratory TestsLaboratory Tests

Tests are rarely indicated to confirm diagnosis.Tests are rarely indicated to confirm diagnosis.o Viral culture of vesicles. (takes several days)Viral culture of vesicles. (takes several days)o Tzank test of skin lesions. (Dermatologist)Tzank test of skin lesions. (Dermatologist)o Direct immunoflurescenceDirect immunoflurescenceo Polymerase chain reaction (PCR). Gold standard.Polymerase chain reaction (PCR). Gold standard.

Baseline labs may be indicatedBaseline labs may be indicatedo Rule out differential dxRule out differential dxo CBC, BMP, ESRCBC, BMP, ESR

NLM (2004)NLM (2004)

Treatment Targets for Treatment Targets for Herpes Zoster / PHNHerpes Zoster / PHN

• Should limit the severity and duration.Should limit the severity and duration.• Should be directed towards prevention of Should be directed towards prevention of

complications.complications.• Accelerate healing process.Accelerate healing process.• Facilitate the persons maximum daily function Facilitate the persons maximum daily function • Avoid all unnecessary side effects of Avoid all unnecessary side effects of

medications.medications.

NEJM (2005)NEJM (2005)

Treatment planTreatment plan1)1) Promote healing ,reduce inflammation and pruritis of the rashPromote healing ,reduce inflammation and pruritis of the rash Domboro solution-OTC- most effective.Domboro solution-OTC- most effective. Calamine lotion-OTCCalamine lotion-OTC Oatmeal soak-OTCOatmeal soak-OTC

2) 2) Reduce viral shedding/DNA replication of the virusReduce viral shedding/DNA replication of the virus Acyclovir-less costly, equal outcome to others, more studies Acyclovir-less costly, equal outcome to others, more studies

performed. 5xs a day dosing can be problemperformed. 5xs a day dosing can be problem Famvir.-more costly but less dosingFamvir.-more costly but less dosing Valtrex-most expensive, less dosing required.Valtrex-most expensive, less dosing required. JAMA 2005, Semla et al 2006,BMJ 2003JAMA 2005, Semla et al 2006,BMJ 2003

Semla et al 2006,BJM 2003Semla et al 2006,BJM 2003

Pain treatment planPain treatment planN.B: N.B: Start low and go Slow in the ElderlyStart low and go Slow in the Elderly

3)3) Treatment of Acute herpetic neuralgia -CTreatment of Acute herpetic neuralgia -Central painentral pain Tylenol -reg Tylenol -reg ↓↓ Tylenol X-tra strength Tylenol X-tra strength ↓↓ Tramadol HCL (use cautiously)Tramadol HCL (use cautiously)

4)4) Treatment of acute herpetic neuralgia-- Treatment of acute herpetic neuralgia--Peripheral pain.Peripheral pain. Lidocaine 5% topical-studies show most effectiveLidocaine 5% topical-studies show most effective Capsaicin topical cream ( if allergy to lidocaine )Capsaicin topical cream ( if allergy to lidocaine )

AJN 2003 Semla et al (2006)AJN 2003 Semla et al (2006)

Pain treatment planPain treatment plan5) 5) Treatment of post- herpetic neuralgia.Treatment of post- herpetic neuralgia. GarbapentinGarbapentin Opioids-(used with extreme caution) Opioids-(used with extreme caution) Opioids-LTC where highly supervised. Community dwelling would Opioids-LTC where highly supervised. Community dwelling would

recommend pain clinic referral.recommend pain clinic referral. Neurology consult / pain clinic is indicated if adequate pain relief is Neurology consult / pain clinic is indicated if adequate pain relief is

not establishednot established

JAMA 2005,JAMA 2005, Semla et al 2006Semla et al 2006

Domboro SolutionDomboro SolutionAluminum Sulfate and calcium Aluminum Sulfate and calcium

acetateacetate

Dosage/treatmentDosage/treatment OTC topical skin product.OTC topical skin product. 1:40 dilution/1 packet in 16 ozs of water1:40 dilution/1 packet in 16 ozs of water Soak affected area 15-20 mins,2-4 times daySoak affected area 15-20 mins,2-4 times dayEffectsEffects ↓ ↓ inflammation,pruritis,↑ drying of vesiclesinflammation,pruritis,↑ drying of vesiclesSide effects/considerationsSide effects/considerations ↑ ↑ local signs may indicate allergic response to solution.local signs may indicate allergic response to solution. Avoid contact with eyes.Avoid contact with eyes. Semla et al(2006)Semla et al(2006)

Acetaminophen / Acetaminophen / TylenolTylenol

Dosage/treatmentDosage/treatment OTC AnalgesiaOTC Analgesia 650mgs PO/PR Q4-6hrs,1000mg PO Q6-8hrs.650mgs PO/PR Q4-6hrs,1000mg PO Q6-8hrs. Reduce TX ↓ renal functionReduce TX ↓ renal function

CrCL : 10-50ml/min =Q6hrsCrCL : 10-50ml/min =Q6hrs

<10 ml/min= Q8<10 ml/min= Q8

Effects/indicationsEffects/indications Mild-moderate painMild-moderate pain Safest/preferred first line therapy for acute herpetic neuralgia in Safest/preferred first line therapy for acute herpetic neuralgia in

the elderlythe elderly VZV foundation guidelinesVZV foundation guidelines

Acetaminophen / Acetaminophen / TylenolTylenol

Side effects/considerationsSide effects/considerations Rash (rare)Rash (rare) Prolonged usage may cause hepatic,anemia,renal impairmentProlonged usage may cause hepatic,anemia,renal impairment Increases/decreases effects of certain drugs.Increases/decreases effects of certain drugs.

(see Semla et al )(see Semla et al ) Avoid alcohol (liver) Avoid alcohol (liver) Reevaluate effect.Reevaluate effect.

Semla et al (2006)BJM 2004Semla et al (2006)BJM 2004

Lidocaine patch 5%Lidocaine patch 5%Dosage/treatmentDosage/treatment 10cms-14cms-700mgs of lidocaine 5%.10cms-14cms-700mgs of lidocaine 5%. 12hrs on 12hrs off.↑ 3 patches can be worn same time12hrs on 12hrs off.↑ 3 patches can be worn same time Safety has been established for longer duration Safety has been established for longer duration

Effects/indicationsEffects/indications Topical anesthetic preferred in the first line treatment of acute/PHNTopical anesthetic preferred in the first line treatment of acute/PHN Treatment of peripheral component of painTreatment of peripheral component of pain

Side effects/considerationsSide effects/considerations Mild transient skin reactionsMild transient skin reactions Do not use in patients with allergy to lidocaine.Do not use in patients with allergy to lidocaine. Do not place over active lesions/broken skinDo not place over active lesions/broken skin

AJN (2003),Semla et al (2006)AJN (2003),Semla et al (2006)

Capsaicin/Zostrix creamCapsaicin/Zostrix cream

Dosage/treatmentDosage/treatment Topical analgesia with mod-poor efficacyTopical analgesia with mod-poor efficacy Apply to affected area 3-4 times a dayApply to affected area 3-4 times a day

Effects/indicationsEffects/indications After repeated application capsaicin depletes substance P the main After repeated application capsaicin depletes substance P the main

chemomediator of pain impulsechemomediator of pain impulse

Side effects/considerationsSide effects/considerations Transient burningTransient burning ErythemaErythema Should not use on broken or irritated skinShould not use on broken or irritated skin Semla et al (2006),BJM (2004)Semla et al (2006),BJM (2004)

Acyclovir / ZoviraxAcyclovir / ZoviraxDosage/treatmentDosage/treatment Anti viral agentAnti viral agent Normal - 800mgs p.o 5xday for 7-10days. Normal - 800mgs p.o 5xday for 7-10days. ADJUST FOR RENAL CLEARANCEADJUST FOR RENAL CLEARANCE Most effective when started within 72 hours of disease onset.Most effective when started within 72 hours of disease onset.

Effects/indications Effects/indications Reduces viral shedding / DNA replicationReduces viral shedding / DNA replication Reduces the intensity and duration of symptoms.Reduces the intensity and duration of symptoms.

Side effects/considerationsSide effects/considerations Lightheadedness, headache,D&V, ABD pain.Lightheadedness, headache,D&V, ABD pain. Use cautiously in renal impairment/nephrotoxic drugs.Use cautiously in renal impairment/nephrotoxic drugs. NLM 2005, Semla et al 2006NLM 2005, Semla et al 2006

Garbapentin / Garbapentin / NeurontinNeurontinDosage/treatmentDosage/treatment

Anticonvulsant used in Neuropathic pain.Anticonvulsant used in Neuropathic pain. 300mg p.o on day 1, 300mg p.o Bid day 2, 300mg p.o Tid on 300mg p.o on day 1, 300mg p.o Bid day 2, 300mg p.o Tid on

day 3,Titrate further as necessary. Doses >1800mg do not day 3,Titrate further as necessary. Doses >1800mg do not generally show greater relief.generally show greater relief.

ADJUST RENAL DOSEADJUST RENAL DOSEEffects/indications Effects/indications FDA approved for Neuropathic pain and it is recommended as FDA approved for Neuropathic pain and it is recommended as

first line therapy for treatment of PHN. first line therapy for treatment of PHN. Side effects/considerationsSide effects/considerations Somnolence, dizziness. D&V, mild edema - (rare)Somnolence, dizziness. D&V, mild edema - (rare) Patients should not use machinery until experience with drug.Patients should not use machinery until experience with drug. National guideline clearing house (2005),Semla et al (2006),Archives of Neurology(2003)National guideline clearing house (2005),Semla et al (2006),Archives of Neurology(2003) Cochrane data base (2006)Cochrane data base (2006)

TramadolTramadolDosage/treatmentDosage/treatment Non narcotic analgesiaNon narcotic analgesia 50-100mg p.o Q 4 hours, NTE 300mg daily50-100mg p.o Q 4 hours, NTE 300mg daily ADJUST FOR RENAL DOSE ADJUST FOR RENAL DOSE Effects/indicationsEffects/indications Use if Tylenol is ineffectiveUse if Tylenol is ineffective Use cautiously in the elderlyUse cautiously in the elderly Relief of moderate to severe painRelief of moderate to severe pain

Side effects/considerationsSide effects/considerations Constipation (consider stool softener)Constipation (consider stool softener) Somnolence, vertigo, nausea,Somnolence, vertigo, nausea, This drug can be habit forming. This drug can be habit forming. Pain(2003) Semla et al (2006)Pain(2003) Semla et al (2006)


What Patient education will you What Patient education will you perform?perform?

Patient EducationPatient Education• Follow complete treatment planFollow complete treatment plan• Potential complicationsPotential complications• When to seek further medical intervention/RTC.When to seek further medical intervention/RTC.• Natural fiber clothingNatural fiber clothing• Prevent infectionPrevent infection• Prevent contact with imunocompromised people, pregnant women and people who have not had Prevent contact with imunocompromised people, pregnant women and people who have not had

chicken pox until vesicles dry up. chicken pox until vesicles dry up. BJM (2005)BJM (2005)

BJM 2003BJM 2003


What patient referrals might you What patient referrals might you make?make?

ReferralsReferrals

• Ophthalmology- Ophthalmic Ophthalmology- Ophthalmic herpes.herpes.

• Neurology/pain center-unrelieved Neurology/pain center-unrelieved painpain

• Urology- urinary complicationsUrology- urinary complications

Additional Notes.Additional Notes.

• Tricyclic antidepressants have been indicated in recent research as Tricyclic antidepressants have been indicated in recent research as successful in the TX PHN , however due to the strong anticholinergic successful in the TX PHN , however due to the strong anticholinergic effect they should not be used as first line treatment. Would recommend effect they should not be used as first line treatment. Would recommend referral to a pain clinic before using these drugs.referral to a pain clinic before using these drugs.

• Epidural steroids have a modest effect on PHN lasting approx 1 month. Epidural steroids have a modest effect on PHN lasting approx 1 month. ( pain clinics usually advocate this if all other methods have been tried)( pain clinics usually advocate this if all other methods have been tried)

• NSAIDS have been successfully used in PHN, however they have the NSAIDS have been successfully used in PHN, however they have the potential to cause gastric bleeding and are hepatotoxic.Would not use as potential to cause gastric bleeding and are hepatotoxic.Would not use as first line TX.first line TX.

Lancet (2006) Beers criteriaLancet (2006) Beers criteria

Complimentary therapyComplimentary therapy

• Very few studies were found on complimentary therapies for Very few studies were found on complimentary therapies for PHN/Neuropathic pain of this nature.PHN/Neuropathic pain of this nature.

Case study in Contemporary hypnosis (2004)Case study in Contemporary hypnosis (2004)• 65 year old man with PHN for 18 months, felt his pain had taken over 65 year old man with PHN for 18 months, felt his pain had taken over

his life.his life.• No psychological problems, happily married.No psychological problems, happily married.• Stated the only time he was pain free was while riding a horseStated the only time he was pain free was while riding a horse• Agreed to try hypnosis and was taught to self hypnotize.Agreed to try hypnosis and was taught to self hypnotize.• Was successful in performing mini trance whenever he felt the pain Was successful in performing mini trance whenever he felt the pain

emerge.emerge.

"Hope for the Future""Hope for the Future"Shingles prevention studyShingles prevention study.. (A joint effort of the V A and National institute of allergy and infectious diseases / Merck & C.O)(A joint effort of the V A and National institute of allergy and infectious diseases / Merck & C.O)

• 38,546 adults > 60yrs enrolled in the study over a 3 year period. At 22 sites.38,546 adults > 60yrs enrolled in the study over a 3 year period. At 22 sites.• Randomized double blind placebo controlled trial of a live attenuated VZV.Randomized double blind placebo controlled trial of a live attenuated VZV.• 957 confirmed cases of HZ ( 315 in the vaccine group,642 in the placebo)957 confirmed cases of HZ ( 315 in the vaccine group,642 in the placebo)• 107 cases of PHN ( 27 in the vaccine group,80 in placebo group)107 cases of PHN ( 27 in the vaccine group,80 in placebo group)• Herpes zoster vaccine reduced the burden of illness by 61%Herpes zoster vaccine reduced the burden of illness by 61% NEJM (2005)NEJM (2005)

NEJM NEJM (2005)(2005)


What future research might be What future research might be indicated? indicated?

Future ResearchFuture Research• Gender / race specific studies in PHN.Gender / race specific studies in PHN.• Exploration of why pain intensifies towards the end of the day.Exploration of why pain intensifies towards the end of the day.• The role of Complimentary therapies: Effect of Hypnosis, relaxation The role of Complimentary therapies: Effect of Hypnosis, relaxation

techniques, therapeutic touch, and Biofeedback have been studied on pain but techniques, therapeutic touch, and Biofeedback have been studied on pain but not in relation to PHN.not in relation to PHN.

• Reduction of emotional stress on the effect of PHNReduction of emotional stress on the effect of PHN• Staff knowledge in LTC on HZ/PHN and level/duration of pain of the patient.Staff knowledge in LTC on HZ/PHN and level/duration of pain of the patient.• Community dwelling Vs facility dwelling on pain related to PHNCommunity dwelling Vs facility dwelling on pain related to PHN• Does socioeconomic status have a bearing on PHNDoes socioeconomic status have a bearing on PHN

VZV VZV Research foundation Research foundation

Implications for the Implications for the GNPGNP

• To continuously review literature/increase knowledge for an improved To continuously review literature/increase knowledge for an improved treatment regime for Herpes Zoster/PHN.treatment regime for Herpes Zoster/PHN.

• Careful assessment , R/O differential DX especially when only Careful assessment , R/O differential DX especially when only prodromal symptoms are present.prodromal symptoms are present.

• Be mindful of cost versus benefits of treatment regime. (Side effects to Be mindful of cost versus benefits of treatment regime. (Side effects to medications, cost of treatment, cost of inadequate treatment).medications, cost of treatment, cost of inadequate treatment).

• Commitment to explore all safe and new treatment options, in Commitment to explore all safe and new treatment options, in particular complimentary therapy.particular complimentary therapy.

• Promote organizational commitment to maintain pain as a number one Promote organizational commitment to maintain pain as a number one priority and promote quality of life of the elderly.priority and promote quality of life of the elderly.

• To maintain membership in professional organizations. ( another way To maintain membership in professional organizations. ( another way to remain current and be a successful patient advocate)to remain current and be a successful patient advocate)

Herpes Zoster

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