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Beyond the Rash: Tackling the Persistent Pain of Postherpetic Neuralgia

Rash with Persistent Pain of Postherpetic Neuralgia and Dr Debjyoti Dutta

Do you know what Postherpetic neuralgia (PHN) is? Understanding this condition is crucial for anyone who has ever suffered from shingles. Looking for relief from the persistent pain of Postherpetic Neuralgia? Discover effective treatments and management strategies beyond the rash.


What is Postherpetic neuralgia (PHN)?


Postherpetic neuralgia (PHN) is characterized by persistent pain after an infection with the Varicella Zoster Virus (VZV). Although there is no unanimous agreement on its precise definition, it is commonly described as lasting for a variable duration following the resolution of a healed Herpes Zoster (HZ) rash. This pain can persist for a period ranging from 4 weeks to six months. The distribution of pain is dermatomal, manifesting as a continual sharp, burning, aching, or shooting sensation within the area where the rash was present. Additionally, individuals often experience hyperalgesia and allodynia.


What are the symptoms of Postherpetic neuralgia (PHN)?


Postherpetic neuralgia (PHN) is characterized by persistent pain that lingers after a shingles (herpes zoster) episode. The symptoms of PHN vary but commonly include the following:

  1. Persistant Pain: The primary symptom is prolonged pain in the area where the shingles rash appeared, manifesting as sharp, burning, stabbing, or throbbing sensations.

  2. Allodynia: Heightened sensitivity to touch, causing pain even with a light touch or gentle pressure on the affected skin.

  3. Hyperalgesia: Increased sensitivity to pain, where mild or moderate stimuli are perceived as more intense.

  4. Itching and Numbness: Some individuals may experience itching or numbness in the affected area.

  5. Discomfort and Irritation: The persistent pain contributes to general discomfort and irritation, impacting the individual's overall well-being.

  6. Sleep Disturbances: Chronic pain can disrupt sleep, leading to challenges in falling or staying asleep.


Factors that predispose individuals to postherpetic neuralgia (PHN) include:


1.     Age and Gender: PHN tends to be more prevalent in elderly males.

2.     Pain Severity during Herpes Zoster: Pain intensity during the initial presentation of Herpes Zoster infection can contribute to the likelihood of developing PHN.

3.     Presence and Duration of Prodromal Symptoms: The existence and duration of pain, dysesthesia, and allodynia before the onset of the rash are influential in PHN development.

4.     Elevated Levels of VZV DNA: Increased levels of Varicella Zoster Virus (VZV) DNA may be associated with a higher risk of PHN.

5.     Surgical Interventions and Mechanical Trauma: PHN risk may be influenced by prior surgical procedures and mechanical trauma.

6.     Smoking: Smoking has been identified as a potential factor that increases susceptibility to PHN.

7.     Depression and Herpes Zoster Severity: The presence of depression and the severity of Herpes Zoster infection are linked to the likelihood of developing PHN.


The Pathophysiology of Postherpetic Neuralgia


While not completely elucidated, the pathophysiology of postherpetic neuralgia (PHN) is thought to result from a complex interplay of peripheral and central sensitization, deafferentiation, activation of neuroglia cells, and prolonged neuronal inflammation.



Can Postherpetic neuralgia (PHN) be Prevented?


Preventing postherpetic neuralgia (PHN) is primarily focused on averting, mitigating the severity, and shortening the duration of Varicella Zoster Virus (VZV) infection. Vaccination using the wild-type VZV Oka strain has been associated with a 66.5% reduction in the incidence of PHN among elderly patients. Initiating antiviral treatment (acyclovir, famciclovir, valacyclovir) within 72 hours of the eruption of Herpes Zoster (HZ) vesicles has demonstrated the ability to expedite the healing process and potentially alleviate the pain burden associated with PHN. However, uncertainty remains regarding whether antiviral therapy can effectively reduce or prevent PHN.

In ongoing investigations, researchers are exploring potential therapeutic approaches. A combination of the antiviral Valacyclovir and gabapentin has shown promise in reducing the incidence of PHN in studies conducted over several months.


How post herpetic neuralgia be treated?


Due to the existing knowledge gap surrounding the precise pathophysiology of postherpetic neuralgia (PHN), specific treatments remain elusive. Consequently, a multidisciplinary approach is commonly employed to address the debilitating effects of PHN. This section focuses on pharmacological interventions:

 

1. Tricyclic Antidepressants:

   - Mechanism: Believed to alleviate pain by inhibiting the reuptake of serotonin and norepinephrine.

   - Common Drugs: Amitriptyline, Nortriptyline, Desipramine.

   - Side Effects: Sedation, postural hypotension, constipation, cognitive decline. QT prolongation is a concern in elderly and cardiac patients.

 

2. Anticonvulsants:

   - Mechanism: Act as membrane stabilizers by binding to the α2β subunit of the L-type calcium channel.

   - Common Drugs: Gabapentin, Pregabalin, Oxcarbazepine.

   - Side Effects: Drowsiness, dizziness, ataxia, mild peripheral edema, potential worsening of cognitive impairment in the elderly.

 

3. Opioids:

   - Mechanism: Exert analgesic effects by acting on opioid receptors involved in pain modulation.

   - Common Drugs: Oxycodone, Morphine, Tramadol.

   - Side Effects: Sedation, constipation, pruritis, nausea, vomiting, postural hypotension. Tramadol poses a unique risk of serotonin syndrome in patients taking certain antidepressants.

 

4. Topical Local Anesthetics:

   - 5% Lidocaine Patch:

      - Mechanism: Inhibits neuronal sodium channels.

      - Common Side Effects: Skin irritation at the application site.

 

5. Capsaicin (Cream/Patch - 0.075%, 8%):

   - Mechanism: Initially excites nociceptive afferents, followed by desensitization of unmyelinated epidermal nerve fibres.

   - Common Side Effects: Local irritation, burning sensation.

 

 

While interventions for postherpetic neuralgia (PHN) may present benefits, their application is most appropriate for cases where traditional medications and conservative approaches prove ineffective. Studies support the efficacy of interventions that are cost-effective and associated with minimal side effects.

 

Interventional Procedures include:

 

  • Peripheral Nerve Blocks: Peripheral nerve blocks encompass the administration of local anaesthetics around affected nerves to impede pain signals. The main emphasis lies on interlaminar injections (with or without steroids), paravertebral injections, and selective sympathetic nerve blocks.

  • Spinal Cord Stimulation: This procedure entails the implantation of electrodes near the spinal cord to disrupt pain signals.


About the Author -

Dr Debjyoti Dutta is a distinguished pain specialist and accomplished author affiliated with Samobathi Pain Clinic and Fortis Hospital in Kolkata. Currently serving as a registrar at the Indian Academy of Pain Medicine, Dr. Dutta specializes in musculoskeletal ultrasound and interventional pain management. Globally recognized for his expertise, he has made significant contributions to the field, including impactful publications such as "Musculoskeletal Ultrasound in Pain Medicine" and "Clinical Methods in Pain Medicine," providing profound insights into the domain of pain management. Beyond his clinical pursuits, Dr. Dutta serves as a faculty member for the Asian Pain Academy Courses, where he plays a pivotal role in delivering top-notch pain management fellowship training in Kolkata, India.

 

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