Herpes Zoster and Postherpetic Neuralgia: Prevention and Management

 

NOTE: On October 25, 2017, the Centers for Disease Control and Prevention's(CDC's) Advisory Committee on Immunization Practices voted to recommend the herpes zoster recombinant subunit vaccine (Shingrix) for healthy adults 50 years and older, including those who previously received Zostavax, to prevent shingles and related complications. This article has been revised to reflect the new recommendations. For more information, visit the CDC page on shingles (herpes zoster) vaccination.

Am Fam Physician. 2017 Nov 15;96(10):656-663.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/shingles.

Author disclosure: No relevant financial affiliations.

Herpes zoster, or shingles, is caused by reactivation of varicella zoster virus, which causes chickenpox. There are an estimated 1 million cases in the Unites States annually, with an individual lifetime risk of 30%. Patients with conditions that decrease cell-mediated immunity are 20 to 100 times more likely to develop herpes zoster. Patients may present with malaise, headache, low-grade fever, and abnormal skin sensations for two to three days before the classic maculopapular rash appears. The rash is usually unilateral, confined to a single dermatome, and typically progresses to clear vesicles that become cloudy and crust over in seven to 10 days. Herpes zoster can be treated with acyclovir, valacyclovir, or famciclovir, ideally within 72 hours of the development of the rash. Postherpetic neuralgia is the most common complication, occurring in about one in five patients. It is defined as pain in a dermatomal distribution sustained for at least 90 days after acute herpes zoster. Treatment is focused on symptom control and includes topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic antidepressants. The varicella zoster virus vaccine decreases the incidence of herpes zoster and is approved for adults 50 years and older. The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends this vaccine for adults 60 years and older, except for certain immunosuppressed patients.

Herpes zoster, or shingles, is caused by reactivation of varicella zoster virus (VZV), which causes chickenpox. It presents as painful blistering and occurs when VZV cell-mediated immunity wanes with age or immunocompromise.1,2 Herpes zoster may be associated with acute pain; postherpetic neuralgia; and visual, neurologic, or visceral complications.3,4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Although herpes zoster typically is diagnosed clinically, if laboratory confirmation is needed, polymerase chain reaction testing of vesicle or other fluids is preferred for diagnosis because of its high sensitivity (95%) and specificity (100%).

C

7

Acyclovir, valacyclovir (Valtrex), and famciclovir are effective treatments for herpes zoster and ideally should be started within 72 hours of the appearance of the rash to decrease the duration of symptoms and severity of pain.

B

1, 2, 7, 1416

Capsaicin 8% patches, applied for 30 to 90 minutes, provide effective pain relief for patients with postherpetic neuralgia.

A

40

Gabapentin (Neurontin) and pregabalin (Lyrica) can be used for treatment of postherpetic neuralgia.

A

42

Amitriptyline, nortriptyline (Pamelor), and desipramine can be used for pain relief in patients with postherpetic neuralgia (number needed to treat = 3; 95% confidence interval, 2 to 4).

A

26, 44

The varicella zoster virus vaccine (Zostavax) should be given to patients 60 years and older, but it is contraindicated in those who are immunosuppressed, have human immunodeficiency virus infection and CD4 lymphocyte counts less than 200 per mm3 (0.20 × 109 per L), are undergoing cancer treatment, or who have cancer affecting the bones or lymphatic system.

A

48, 50, 51


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Although herpes zoster typically is diagnosed clinically, if laboratory confirmation is needed, polymerase chain reaction testing of vesicle or other fluids is preferred for diagnosis because of its high sensitivity (95%) and specificity (100%).

C

7

Acyclovir, valacyclovir (Valtrex), and famciclovir are effective treatments for herpes zoster and ideally should be started within 72 hours of the appearance of the rash to decrease the duration of symptoms and severity of pain.

B

1, 2, 7, 1416

Capsaicin 8% patches, applied for 30 to 90 minutes, provide effective pain relief for patients with postherpetic neuralgia.

A

40

Gabapentin (Neurontin) and pregabalin (Lyrica) can be used for treatment of postherpetic neuralgia.

A

42

Amitriptyline, nortriptyline (Pamelor), and desipramine can be used for pain relief in patients with postherpetic neuralgia (number needed to treat = 3; 95% confidence interval, 2 to 4).

A

26, 44

The varicella zoster virus vaccine (Zostavax) should be given to patients 60 years and older, but it is contraindicated in those who are immunosuppressed, have human immunodeficiency virus infection and CD4 lymphocyte counts less than 200 per mm3 (0.20 × 109 per L), are undergoing cancer treatment, or who have cancer affecting the bones or lymphatic system.

A

48, 50, 51


A = consistent, good-quality patient-oriented e

The Authors

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AARON SAGUIL, MD, MPH, is an associate professor in the Department of Family Medicine at F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md....

SHAWN KANE, MD, is an assistant professor in the Department of Family Medicine at F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences.

MICHAEL MERCADO, MD, is an assistant professor in the Department of Family Medicine at F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences.

REBECCA LAUTERS, MD, is chief resident in the Department of Family Medicine at Nellis Family Medicine Residency, Mike O'Callaghan Federal Medical Center, Nellis Air Force Base, Nev.

Address correspondence to Aaron Saguil, MD, MPH, 4301 Jones Bridge Rd., Bethesda, MD 20814 (e-mail: aaron.saguil@usuhs.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Sauerbrei A. Diagnosis, antiviral therapy, and prophylaxis of varicella-zoster virus infections. Eur J Clin Microbiol Infect Dis. 2016;35(5):723–734....

2. O'Connor KM, Paauw DS. Herpes zoster. Med Clin North Am. 2013;97(4):503–522, ix.

3. Weinberg JM. Herpes zoster: epidemiology, natural history, and common complications. J Am Acad Dermatol. 2007;57(6 suppl):S130–S135.

4. Panatto D, Bragazzi NL, Rizzitelli E, et al. Evaluation of the economic burden of herpes zoster (HZ) infection. Hum Vaccin Immunother. 2015;11(1):245–262.

5. Johnson BH, Palmer L, Gatwood J, Lenhart G, Kawai K, Acosta CJ. Annual incidence rates of herpes zoster among an immunocompetent population in the United States. BMC Infect Dis. 2015;15:502.

6. Hambleton S, Steinberg SP, Larussa PS, Shapiro ED, Gershon AA. Risk of herpes zoster in adults immunized with varicella vaccine. J Infect Dis. 2008;197(suppl 2):S196–S199.

7. Cohen JI. Clinical practice: Herpes zoster. N Engl J Med. 2013;369(3):255–263.

8. Weaver BA. Herpes zoster overview: natural history and incidence. J Am Osteopath Assoc. 2009;109(6 suppl 2):S2–S6.

9. Gnann JW Jr, Whitley RJ. Clinical practice. Herpes zoster. N Engl J Med. 2002;347(5):340–346.

10. GoodRx. http://www.goodrx.com. Accessed May 22, 2016.

11. Epocrates Rx. (2016). Epocrates Essentials for Android (Version 16.10) [Mobile application software]. Retrieved from https://play.google.com/store/apps/developer?id=Epocrates,+Inc.&hl=en. Accessed June 13, 2017.

12. Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med. 1994;330(13):896–900.

13. Whitley RJ, Weiss H, Gnann JW Jr, et al.; The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial. Ann Intern Med. 1996;125(5):376–383.

14. McKendrick MW, McGill JI, White JE, Wood MJ. Oral acyclovir in acute herpes zoster. Br Med J (Clin Res Ed). 1986;293(6561):1529–1532.

15. Beutner KR, Friedman DJ, Forszpaniak C, Andersen PL, Wood MJ. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother. 1995;39(7):1546–1553.

16. Shafran SD, Tyring SK, Ashton R, et al. Once, twice, or three times daily famciclovir compared with aciclovir for the oral treatment of herpes zoster in immunocompetent adults: a randomized, multicenter, double-blind clinical trial. J Clin Virol. 2004;29(4):248–253.

17. Chen N, Li Q, Yang J, Zhou M, Zhou D, He L. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2014;(2):CD006866.

18. Han Y, Zhang J, Chen N, He L, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev. 2013;(3):CD005582.

19. National Institute for Health and Care Excellence. Neuropathic Pain: The Pharmacological Management of Neuropathic Pain in Adults in Non-specialist Settings. London, UK: National Institute for Health and Care Excellence; 2013.

20. Hooten M, Thorson D, Bianco J, et al.; Institute for Clinical Systems Improvement. Pain: assessment, non-opioid treatment approaches and opioid management. September 2016. https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_neurological_guidelines/pain/. Accessed July 13, 2017.

21. Fashner J, Bell AL. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2011;83(12):1432–1437.

22. Dworkin RH, Barbano RL, Tyring SK, et al. A randomized, placebo-controlled trial of oxycodone and of gabapentin for acute pain in herpes zoster. Pain. 2009;142(3):209–217.

23. Shannon HJ, Anderson J, Damle JS. Evidence for interventional procedures as an adjunct therapy in the treatment of shingles pain. Adv Skin Wound Care. 2012;25(6):276–284.

24. Makharita MY, Amr YM, El-Bayoumy Y. Single para-vertebral injection for acute thoracic herpes zoster: a randomized controlled trial. Pain Pract. 2015;15(3):229–235.

25. Liang L, Li X, Zhang G, Sun Y, Yu H, Jiao J. Pregabalin in the treatment of herpetic neuralgia: results of a multi-center Chinese study. Pain Med. 2015;16(1):160–167.

26. Moore RA, Derry S, Aldington D, Cole P, Wiffen PJ. Amitriptyline for neuropathic pain in adults. Cochrane Database Syst Rev. 2015;(7):CD008242.

27. Johnson RW, Rice AS. Clinical practice. Postherpetic neuralgia. N Engl J Med. 2014;371(16):1526–1533.

28. Massengill JS, Kittredge JL. Practical considerations in the pharmacological treatment of postherpetic neuralgia for the primary care provider. J Pain Res. 2014;7:125–132.

29. Yawn BP, Gilden D. The global epidemiology of herpes zoster. Neurology. 2013;81(10):928–930.

30. Hadley GR, Gayle JA, Ripoll J, et al. Postherpetic neuralgia: a review [published correction appears in Curr Pain Headache Rep. 2016;20(4):28]. Curr Pain Headache Rep. 2016;20(3):17.

31. Drolet M, Brisson M, Schmader K, et al. Predictors of postherpetic neuralgia among patients with herpes zoster: a prospective study. J Pain. 2010;11(11):1211–1221.

32. Forbes HJ, Thomas SL, Smeeth L, et al. A systematic review and meta-analysis of risk factors for postherpetic neuralgia. Pain. 2016;157(1):30–54.

33. Kawai K, Rampakakis E, Tsai TF, et al. Predictors of postherpetic neuralgia in patients with herpes zoster: a pooled analysis of prospective cohort studies from North and Latin America and Asia. Int J Infect Dis. 2015;34:126–131.

34. Pickering G, Leplege A. Herpes zoster pain, postherpetic neuralgia, and quality of life in the elderly. Pain Pract. 2011;11(4):397–402.

35. Watson CP, Watt VR, Chipman M, Birkett N, Evans RJ. The prognosis with postherpetic neuralgia. Pain. 1991;46(2):195–199.

36. Harden RN, Kaye AD, Kintanar T, Argoff CE. Evidence-based guidance for the management of postherpetic neuralgia in primary care. Postgrad Med. 2013;125(4):191–202.

37. Thakur R, Philip AG. Chronic pain perspectives: Treating herpes zoster and postherpetic neuralgia: an evidence-based approach. J Fam Pract. 2012;61(9 suppl):S9–S15.

38. Davies PS, Galer BS. Review of lidocaine patch 5% studies in the treatment of postherpetic neuralgia. Drugs. 2004;64(9):937–947.

39. Derry S, Wiffen PJ, Moore RA, Quinlan J. Topical lidocaine for neuropathic pain in adults. Cochrane Database Syst Rev. 2014;(7):CD010958.

40. Derry S, Sven-Rice A, Cole P, Tan T, Moore RA. Topical capsaicin (high concentration) for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2013;(2):CD007393.

41. Derry S, Moore RA. Topical capsaicin (low concentration) for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2012;(9):CD010111.

42. Wiffen PJ, Derry S, Moore RA, et al. Antiepileptic drugs for neuropathic pain and fibromyalgia—an overview of Cochrane reviews. Cochrane Database Syst Rev. 2013;(11):CD010567.

43. Johnson P, Becker L, Halpern R, Sweeney M. Real-world treatment of post-herpetic neuralgia with gabapentin or pregabalin. Clin Drug Investig. 2013;33(1):35–44.

44. Hempenstall K, Nurmikko TJ, Johnson RW, A'Hern RP, Rice AS. Analgesic therapy in postherpetic neuralgia: a quantitative systematic review. PLoS Med. 2005;2(7):e164.

45. McNicol ED, Midbari A, Eisenberg E. Opioids for neuropathic pain. Cochrane Database Syst Rev. 2013;(8):CD006146.

46. Hollingshead J, Dühmke RM, Cornblath DR. Tramadol for neuropathic pain. Cochrane Database Syst Rev. 2006;(3):CD003726.

47. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. Pain Med. 2009;10(6):1062–1083.

48. Crawford C; American Academy of Family Physicians. ACIP recommends new herpes zoster subunit vaccine. October 31, 2017. https://www.aafp.org/news/health-of-the-public/20171031acipmeeting.html. Accessed November 16, 2017.

49. Lal H, Cunningham AL, Godeaux O, et al.; ZOE-50 Study Group. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med. 2015;372(22):2087–2096.

50. Kim DK, Riley LE, Harriman KH, Hunter P, Bridges CB. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older—United States, 2017. MMWR Morb Mortal Wkly Rep. 2017;66(5):136–138.

51. Tseng HF, Harpaz R, Luo Y, et al. Declining effectiveness of herpes zoster vaccine in adults aged ≤ 60 years. J Infect Dis. 2016;213(12):1872–1875.

52. Williams WW, Lu PJ, O'Halloran A, et al.; Centers for Disease Control and Prevention (CDC). Vaccination coverage among adults, excluding influenza vaccination—United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64(4):95–102.

53. Fashner J, Bell AL. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2011;83(12):1432–1437.

54. Mounsey AL, Matthew LG, Slawson DC. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2005;72(6):1075–1080.

55. Stankus SJ, Dlugopolski M, Packer D. Management of herpes zoster (shingles) and postherpetic neuralgia. Am Fam Physician. 2000;61(8):2437–2444.

 

 

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