Herpes Zoster and Post herpetic Neuralgia:

1
Herpes Zoster and Post herpetic Neuralgia

• Evidenced based guidelines for the Gerontological
  Nurse Practioner.
• Tracy Ann Ramos BS , R N.
• April 6, 2006

2
Presentation Objectives.

• Identify the risk factors and clinical
  manifestations of herpes zoster and potential
  complications in the older adult.
• Briefly review the epidemiology, Pathophysiology
  and diagnoses of herpes zoster and its
  complications.
• Recognize the burden of illness of herpes zoster
  through discussion of recent research findings
  and clinical data.
• Articulate evidence based therapeutic solutions,
  (Non- pharmacological, pharmacological and
  complimentary therapies) to the management of
  post-herpetic neuralgia there by improving the
  quality of life of the older adult.
• Discuss the implications of the GNP role in the
  management and future research of post-hepatic
  neuralgia.

3
Role and responsibilities of the GNP in the
treatment of Herpes zoster and PHN.

• Assisting the older adult to function at his or
  hers highest level.
• Assisting the older adult in minimizing health
  risks.
• Providing information, education and resources to
  older adults.
• Recognizing and addressing the frequently
  atypical response of older adults to disease and
  its treatments.
• Scope and
  Standards of Gerontological Nursing (2002)

4
Role and responsibilities of the GNP in the
treatment of Herpes Zoster and PHN.

• Assessment, treatment and evaluation methodology
  based on evidenced based practice.
• Collaboration with the older adult, caregiver and
  all members of the healthcare team to provide
  comprehensive care.
• Provide guidance and care to the older adult that
  respects human dignity and the uniqueness of the
  individual.
• Considers factors related to safety
  ,effectiveness and cost in planning and
  delivering patient care.
• Scope
  and Standards of Gerontological Nursing (2002)

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Definitions

• Herpes Zoster
• Acute, localized infection of the
  Varicella-Zoster virus, which causes a painful
  blistering, pruritic rash.
• Post-Herpetic Neuralgia
• Pain that persists for more than 1 month after
  the onset of Herpes zoster.
  
• 
  
  U.S Library of medicine 2006, Journal of
  Family practice(2003)
• 
  
  
  

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Historical Perspective

• The Varicella-Zoster Virus is estimated to have
  been around 70 million years.
• Initially named by Hippocrates
• herpesto creep, Zoster girdle (Greek)
• Shingles belt, (Latin).
• Not until 1940 was the etiology of the virus
  established.
• VZV was finally isolated in 1952 by a Harvard
  Microbiologist.
• Finally sequenced in 1986.
• 
  Archives of Neurology ( 2004)

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Question ?

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

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Epidemiology/ Etiology

• 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 exposure to
  Varicella.
• The childhood Varicella vaccine may ultimately
  reduce the incidence of Herpes Zoster.
• Rarely seen lt 50 years of age.
• 30 of previously immune persons gt 60yrs have no
  detectable antibodies. VZV is a 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
  simplex.
• Journal of family practice(2003), BMJ
  (2003)

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Epidemiology/ Etiology

• Following primary infection of the virus
  (Varicella -chicken pox), it lies dormant until
  reactivated in later life. (Herpes
  Zoster-shingles)
• The virus lies dormant in the sensory nerve
  ganglia, dorsal root and cranial nerve ganglia.
• Reactivation of the virus is linked to a
  reduction of cell mediated immunity. (Age,
  immuno-compromised)
• Generally involves the skin of a single dermatome
  
• 15-35 of patients with Herpes Zoster will
  develop PHN
• African Americans are 1/4th as likely to develop
  Herpes Zoster
• 
  Postgraduate medicine
  (2005),Journal of pain(2005) .
• 
  Management guidelines for NPs working with
  older adults.(FADavis,2004)

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Pathophysiology of Herpes Zoster

• Reactivation can occur in the presence of stress,
  surgery, or injury.
• Following reactivation the virus travels at a
  possible rate of 1.7-10mm per hour. Estimated
  time for the virus to leave the ganglion and
  reach the peripheral nerve and the development of
  cutaneous vesicles is 48-96 hours.
• Hemorrhagic inflammation is characterized at the
  cellular level.
• Fibrosis is noted at the dorsal root ganglion,
  nerve root and peripheral nerve upon resolution
  of the acute stage.
• 
  The journal of Urology (2003)

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Risk Factors for PHN

• Replicated risk factors.
• Older age
• Greater acute pain
• Severity of rash
• History of a prodrome.
• Less well replicated risk factors.
• Female gender
• Greater sensory abnormalities in the affected
  dermatome
• Polyneuropathy,brainstem and cervical cord
  abnormalities.
• Psychosocial variables
• Lancet(2006) Journal of pain(2005)

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Clinical Manifestations of Herpes zoster.

• Prodrome symptoms may include chills, fever,
  malaise, G.I. disturbance and parasthesia or
  neuralgia along the affected dermatome.
• Red papules usually appear along the affected
  dermatome within 3 days.( usually last for ltday)
• The eruption of vesicles closely follows the
  maculopapular rash.
• Vesicles are fluid filled and can transmit the
  virus, usually dry up in an average of 7 days.
• Scarring may occur at the site.
• 
  MahanButtarro 2006, Merck manual of
  geriatrics (2000)

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Clinical Manifestations of Herpes zoster.

• Distribution 50-60 Thoracic, 10-20Trigeminal,
  10-20Cervical, 5-10 Lumbar, and lt5 Sacral.
• 99 of all cases are unilateral and do not cross
  the midline unless there is gt one dermatome
  affected or dissemination has occurred.
  (immune-compromised)
• Neuropathic pain may precede the onset of the
  rash or develop simultaneously . (Acute herpetic
  neuralgia)
• Without complications HZ typically lasts 2-4
  weeks.
• 
  
  NLM
  (2006) Mahan Buttaro 2006, Merck manual of
  geriatrics (2000)
• Merck Manual of geriatrics(2000)

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Herpes vesicles
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Ophthalmic Herpes zoster
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Hutchinson sign
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Ramsey Hunt syndrome
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Question ?

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

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Burden of illness

• A cross sectional survey performed on 84 patients
  with PHN in 6 European countries.- Results
• Developed sleep disorder.
• Anxiety
• Depression
• Decreased walking ability (depending on
  dermatome)
• Withdrawal from relationships / activities.
• Reduction in the general enjoyment of life.
• Age and aging, Oxford University,U.K
  (2006)

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Question ?

• What could be the differential diagnoses given
  these symptoms ?

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Differential Diagnoses of Herpes Zoster

• Herniated disc.
• M I
• Acute abdomen
• Musculoskeletal disorder.
• Pleurisy
• Migraine headache / Temporal artritis, Trigeminal
  neuralgia.
• Polymyalgia rheumatica
  
  Merck Manual of Geriatrics
  (2000)/postgrad medicine (2005)

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Complications of Herpes Zoster

• Bacterial infection of the skin.-requires ABT
• Corneal scarring /vision loss/conjunctivitis-immed
  iate referral if eyes are involved.
• Encephalitis
• Guillain- Barre Syndrome.
• Urinary retention.
• Bells Palsy ( Zoster sine herpetic )
• Cochlear vesicular involvement (Ramsey hunt
  syndrome)
• Loss of taste Merck
  Manual of Geriatrics(2000)BMj 2004

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Clinical Presentation of PHN

• Pain that persists for more than a month
  following the onset of Herpes Zoster.
• Pain may last months or in a few cases over a
  year.
• Pain is described as lacinating, burning,
  shooting, stabbing, paroxysmal or electrical.
• Allodynia occurs.( pain in reaction to a non-
  noxious stimulai,light touch, clothing).
• Pain can be debilitating and interfere with daily
  functioning .
• Pain ? through out the day
• Pain has 2 components 1) Central , 2)
  Peripheral.
• 
  JAMA (2005), Pain (2006)

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Question?

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

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Patient history/ROS

• PMH Chicken pox, recent contacts, recent
  surgeries,current/ ongoing therapies, recent
  illness. Comorbidities.
• Social/History Stress, lifestyle habits,
  support system/caregivers.
• Current state of health Pain, (Old CART).?
  Dermatome,. Ask questions pertaining to rash.
• ? Allodynia (sensitive to fine touch), ?
  Hyperalgesia (abnormally low sensitivity to
  pain), ? Dysethesia (pins and needles, worms) .
• Ask questions pertinent to particular dermatome
  involved.
• Activities of daily living/quality of life.
• Rule out differential diagnoses. Journal of
  pain(2004)
  
  Anesthesia Analgesia (2003)

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Question ?

• What parts of the physical exam will you
  perform ?

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Physical Examination

• General survey.
• Skin inspection.
• Inspection of the rash if present.
• Location of dermatome, (exam system above and
  below)
• Neurological assessment of the affected
  dermatome. (vibration sense)
• Test for allodynia using cotton wool balls and
  sharp object.
• Adapt you assessment to the cognitively impaired
  person

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Diagnostic Criteria

• Diagnoses of Herpes Zoster / PHN is primarily
  clinical presentation (May be all or some of the
  following)
• History of chicken pox in younger years
• Presence of prodromal symptoms
• Possible eruption of Maculopapular / vesicular
  rash.
• Neuropathic pain that follows the dermatomal
  path.
• Possible presence of either or all Allodynia ,
  Hyperalgesia, Dysethesia.
• Positive PCR
• 
  CDC guidelines 2005,Merck
  Manual 2000

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Laboratory Tests

• Tests are rarely indicated to confirm diagnosis.
• Viral culture of vesicles. (takes several days)
• Tzank test of skin lesions. (Dermatologist)
• Direct immunoflurescence
• Polymerase chain reaction (PCR). Gold standard.
• Baseline labs may be indicated
• Rule out differential dx
• CBC, BMP, ESR
• 
  
  
  NLM (2004)

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Treatment Targets for Herpes Zoster / PHN

• Should limit the severity and duration.
• Should be directed towards prevention of
  complications.
• Accelerate healing process.
• Facilitate the persons maximum daily function
• Avoid all unnecessary side effects of
  medications.
• 
  
  NEJM (2005)

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Treatment plan

• 1) Promote healing ,reduce inflammation and
  pruritis of the rash
• Domboro solution-OTC- most effective.
• Calamine lotion-OTC
• Oatmeal soak-OTC
• 2) Reduce viral shedding/DNA replication of the
  virus
• Acyclovir-less costly, equal outcome to others,
  more studies performed. 5xs a day dosing can be
  problem
• Famvir.-more costly but less dosing
• Valtrex-most expensive, less dosing required.
• 
  JAMA 2005, Semla et al
  2006,BMJ 2003
• 
  
  Semla et al 2006,BJM 2003

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Pain treatment plan

• N.B Start low and go Slow in the Elderly
• 3) Treatment of Acute herpetic neuralgia -Central
  pain
• Tylenol -reg ?
• Tylenol X-tra strength ?
• Tramadol HCL (use cautiously)
• 4) Treatment of acute herpetic neuralgia--Peripher
  al pain.
• Lidocaine 5 topical-studies show most effective
• Capsaicin topical cream ( if allergy to lidocaine
  )
• 
  
  AJN 2003 Semla et al (2006)

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Pain treatment plan

• 5) Treatment of post- herpetic neuralgia.
• Garbapentin
• Opioids-(used with extreme caution)
• Opioids-LTC where highly supervised. Community
  dwelling would recommend pain clinic referral.
• Neurology consult / pain clinic is indicated if
  adequate pain relief is not established
• 
  
  JAMA 2005, Semla et al
  2006

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Domboro SolutionAluminum Sulfate and calcium
acetate

• Dosage/treatment
• OTC topical skin product.
• 140 dilution/1 packet in 16 ozs of water
• Soak affected area 15-20 mins,2-4 times day
• Effects
• ? inflammation,pruritis,? drying of vesicles
• Side effects/considerations
• ? local signs may indicate allergic response to
  solution.
• Avoid contact with eyes.
• 
  
  Semla et al(2006)

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Acetaminophen / Tylenol

• Dosage/treatment
• OTC Analgesia
• 650mgs PO/PR Q4-6hrs,1000mg PO Q6-8hrs.
• Reduce TX ? renal function
• CrCL 10-50ml/min Q6hrs
• lt10 ml/min Q8
• Effects/indications
• Mild-moderate pain
• Safest/preferred first line therapy for acute
  herpetic neuralgia in the elderly
• 
  
  VZV foundation guidelines

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Acetaminophen / Tylenol

• Side effects/considerations
• Rash (rare)
• Prolonged usage may cause hepatic,anemia,renal
  impairment
• Increases/decreases effects of certain drugs.
• (see Semla et al )
• Avoid alcohol (liver)
• Reevaluate effect.
• 
  
  Semla et al (2006)BJM 2004

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Lidocaine patch 5

• Dosage/treatment
• 10cms-14cms-700mgs of lidocaine 5.
• 12hrs on 12hrs off.? 3 patches can be worn same
  time
• Safety has been established for longer duration
• Effects/indications
• Topical anesthetic preferred in the first line
  treatment of acute/PHN
• Treatment of peripheral component of pain
• Side effects/considerations
• Mild transient skin reactions
• Do not use in patients with allergy to lidocaine.
• Do not place over active lesions/broken skin
• AJN
  (2003),Semla et al (2006)

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Capsaicin/Zostrix cream

• Dosage/treatment
• Topical analgesia with mod-poor efficacy
• Apply to affected area 3-4 times a day
• Effects/indications
• After repeated application capsaicin depletes
  substance P the main chemomediator of pain
  impulse
• Side effects/considerations
• Transient burning
• Erythema
• Should not use on broken or irritated skin
• 
  
  Semla et al (2006),BJM (2004)

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Acyclovir / Zovirax

• Dosage/treatment
• Anti viral agent
• Normal - 800mgs p.o 5xday for 7-10days.
• ADJUST FOR RENAL CLEARANCE
• Most effective when started within 72 hours of
  disease onset.
• Effects/indications
• Reduces viral shedding / DNA replication
• Reduces the intensity and duration of symptoms.
• Side effects/considerations
• Lightheadedness, headache,DV, ABD pain.
• Use cautiously in renal impairment/nephrotoxic
  drugs.
• 
  
  NLM 2005, Semla et al 2006

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Garbapentin / Neurontin

• Dosage/treatment
• Anticonvulsant used in Neuropathic pain.
• 300mg p.o on day 1, 300mg p.o Bid day 2, 300mg
  p.o Tid on day 3,Titrate further as necessary.
  Doses gt1800mg do not generally show greater
  relief.
• ADJUST RENAL DOSE
• Effects/indications
• FDA approved for Neuropathic pain and it is
  recommended as first line therapy for treatment
  of PHN.
• Side effects/considerations
• Somnolence, dizziness. DV, mild edema - (rare)
• Patients should not use machinery until
  experience with drug.
• National guideline clearing house
  (2005),Semla et al (2006),Archives of
  Neurology(2003)
• 
  Cochrane
  data base (2006)

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Tramadol

• Dosage/treatment
• Non narcotic analgesia
• 50-100mg p.o Q 4 hours, NTE 300mg daily
• ADJUST FOR RENAL DOSE
• Effects/indications
• Use if Tylenol is ineffective
• Use cautiously in the elderly
• Relief of moderate to severe pain
• Side effects/considerations
• Constipation (consider stool softener)
• Somnolence, vertigo, nausea,
• This drug can be habit forming.
• 
  Pain(2003) Semla et al (2006)

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Question ?

• What Patient education will you perform?

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Patient Education

• Follow complete treatment plan
• Potential complications
• When to seek further medical intervention/RTC.
• Natural fiber clothing
• Prevent infection
• Prevent contact with imunocompromised people,
  pregnant women and people who have not had
  chicken pox until vesicles dry up.
• 
  
  BJM
  (2005)
• BJM 2003

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Question ?

• What patient referrals might you make?

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Referrals

• Ophthalmology- Ophthalmic herpes.
• Neurology/pain center-unrelieved pain
• Urology- urinary complications

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Additional Notes.

• Tricyclic antidepressants have been indicated in
  recent research as successful in the TX PHN ,
  however due to the strong anticholinergic effect
  they should not be used as first line treatment.
  Would recommend referral to a pain clinic before
  using these drugs.
• Epidural steroids have a modest effect on PHN
  lasting approx 1 month. ( pain clinics usually
  advocate this if all other methods have been
  tried)
• NSAIDS have been successfully used in PHN,
  however they have the potential to cause gastric
  bleeding and are hepatotoxic.Would not use as
  first line TX.
• 
  Lancet (2006) Beers criteria

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Complimentary therapy

• Very few studies were found on complimentary
  therapies for PHN/Neuropathic pain of this
  nature.
• Case study in Contemporary hypnosis (2004)
• 65 year old man with PHN for 18 months, felt his
  pain had taken over his life.
• No psychological problems, happily married.
• Stated the only time he was pain free was while
  riding a horse
• Agreed to try hypnosis and was taught to self
  hypnotize.
• Was successful in performing mini trance whenever
  he felt the pain emerge.

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"Hope for the Future"

• Shingles prevention study. (A joint effort of the
  V A and National institute of allergy and
  infectious diseases / Merck C.O)
• 38,546 adults gt 60yrs enrolled in the study over
  a 3 year period. At 22 sites.
• 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)
• 107 cases of PHN ( 27 in the vaccine group,80 in
  placebo group)
• Herpes zoster vaccine reduced the burden of
  illness by 61
• 
  NEJM (2005)
• 
  
  NEJM (2005)

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Question ?

• What future research might be indicated?

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Future Research

• Gender / race specific studies in PHN.
• Exploration of why pain intensifies towards the
  end of the day.
• The role of Complimentary therapies Effect of
  Hypnosis, relaxation techniques, therapeutic
  touch, and Biofeedback have been studied on pain
  but not in relation to PHN.
• Reduction of emotional stress on the effect of
  PHN
• Staff knowledge in LTC on HZ/PHN and
  level/duration of pain of the patient.
• Community dwelling Vs facility dwelling on pain
  related to PHN
• Does socioeconomic status have a bearing on PHN
• 
  VZV Research foundation
  

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Implications for the GNP

• To continuously review literature/increase
  knowledge for an improved treatment regime for
  Herpes Zoster/PHN.
• Careful assessment , R/O differential DX
  especially when only prodromal symptoms are
  present.
• Be mindful of cost versus benefits of treatment
  regime. (Side effects to medications, cost of
  treatment, cost of inadequate treatment).
• Commitment to explore all safe and new treatment
  options, in particular complimentary therapy.
• Promote organizational commitment to maintain
  pain as a number one priority and promote quality
  of life of the elderly.
• To maintain membership in professional
  organizations. ( another way to remain current
  and be a successful patient advocate)