Herpes Zoster and Quality of Life

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Herpes Zoster and Quality of Life

• Antonio Volpi
• University of Rome Tor Vergata

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The scene

• The most debilitating symptom of Herpes Zoster is
  the associated pain
  
• The correlation between zoster associated pain
  and quality of life has been the object of
  numerous studies
  
• Zoster associated pain and discomfort result to
  have a significant negative impact on the
  patients, but their grade appears dependent on
  the instrument used, setting and population

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Pain

• Acute pain is reported in over 80 of the cases
  of herpes zoster and PHN in 2 to 30 of the
  patients, but these figures can vary according to
  different definitions
• There may be important pathogenetic differences
  in herpes zoster, yet to be elucidated, all
  resulting in pain and abnormal sensations
  

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Definitions to rate pain

• ZBPI an 11-point Likert scale (0 to 10) to rate
  pain in 4 ways (worst, least, and average in the
  last 24 h and now)
  
• 4 measures ratings of average and worst shingles
  pain on a numerical rating scale (NRS) of 0 to
  100 and ratings of average and worst shingles
  pain on the McGill Pain Questionnaire (MPQ)
  Present Pain Intensity (PPI) verbal rating scale
• VAS 1 nil, 10 maximum
• At visit
• In the last 24 hrs
• In the last week
• Categorization (mild, moderate, severe) without
  other indications

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Median acute pain scores
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Abnormal sensations

• Abnormal sensations (including itch, loss of
  sensation and allodinia), which are not normally
  classified as pain, can be present in up to one
  third of the patients.
• In some studies they are reported in addition or
  in association with pain
  
• Their influence in the QoL is not well studied

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Quality of life

• Several studies which explored QoL during acute
  herpes zoster and PHN in different setting and
  using different tests, showed similar results
  
• QoL is felt greatly reduced both during acute
  phase of herpes zoster and PHN by almost all the
  patients and the reduction is normally associated
  with the intensity of pain
• The majority of the studies rely on judgment made
  by the patients themselves about their health
  status

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Psychological issues

• Anxiety and depression are common during the
  acute phase of herpes zoster and appear
  correlated to the intensity of pain
  
• Up to 40 of the patients had experienced
  important events described as negative during the
  last 3 months before the onset of symptoms
  
• It is difficult to assess if anxiety and
  depression precede or are associated with the
  disease

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Psychological issues

• Anxiety and depression persist in the majority of
  the patients with chronic pain, but tend to
  decrease or disappear with the cessation of the
  herpes associated pain
• In the majority of the studies anxiety and
  depression do not predict the development of PHN
  
• Personality disorders, disease conviction and
  trust in healthcare are, however, predictors of
  PHN

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Psychosocial characteristics of HZ patients at
the baseline and at the 6-month follow-up visit
(median values of the scores)
Volpi A 2007 (submitted)
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Barriers to comprehensive management

• Lack of clear initial symptoms due to variable
  nature of prodromal pain and patients fear of
  illness
  
• Lack of physician awareness of patients
  suffering
  
• Lack of clear guidelines to improve the patients
  discomfort even if, almost always, the available
  treatments must be personalized
  

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Conclusions

• QoL is greatly impaired by herpes zoster, mainly
  due to the pain and/or abnormal sensations that
  are a common feature of the disease
  
• Prompt antiviral therapy reduces the time in
  which the patient is in pain
  
• Studies are ongoing to determine if more
  aggressive analgesic treatment of the acute HZ
  pain will further reduce the risk of chronic pain.

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Conclusions

• It is very likely that pain in patients with
  herpes zoster is often inadequately treated in
  clinical practice
  
• Fear of the disease and low trust in healthcare
  can itself impair QoL
  
• A more comprehensive approach to the patients
  with acute herpes zoster is needed to reduce the
  burden of the disease