Canfamphys00096 0115
Canfamphys00096 0115
Canfamphys00096 0115
management of
SUMMARY
Herpes zoster is an infection
herpes zoster and
caused by reactivation of
dormant varicella-zoster virus.
The acute course of herpes
zoster is generally benign;
postherpetic
however, some patients will
experience postherpetic
neuralgia characterized by neuralgia
severe, relentless, and at times
disabling pain that is often FATIMA S. MAMDANI, BSC PHARM
refractory to treatment. While
herpes zoster responds to
acyclovir, cost-benefit
considerations limit the drug's
usefulness to only a select
group. Postherpetic neuralgia ERPES ZOSTER (HZ), OR In addition to the elderly, immuno-
requires a holistic approach, "shingles," produces an
4
compromised patients, particularly those
including pharmacologic therapy acute segmental neuralgia, suffering from hematologic or reticuloen-
using several different classes which - although painful - dothelial malignancies, have a greater risk
of drugs. is fortunately transient in of developing HZ.4-6 Furthermore, HZ
most patients. Morbidity associated with might be the first clinical manifestation of
RESUME this infection is more prevalent among the HIV infection. In a study among 48 HZ
Le zona (herpes zoster) est elderly and immunocompromised, partic- patients, 35 (73%) were seropositive for
une infection causee par la ularly those who develop postherpetic HIV on the initial day of diagnosis of HZ.
reactivation de la phase
dormante de l'herpes virus neuralgia (PHN), a complication that Of these, 34 (97%) were known to be at
varicellae. Le zona est une could become a clinician's nightmare. high risk for AIDS.7
infection aigue dont l'evolution This review discusses the clinical features Therefore, among patients at risk for
est habituellement benigne mais and pharmacologic management of both AIDS, the occurrence of HZ might pre-
certains patients souffriront these entities. cede the marked depression of cellular
d'une nevralgie postzosterienne immunity associated with AIDS or
caracterisee par des douleurs Epidemiology of HZ AIDS-related complex. Similarly, a greater
intenses et continuelles, parfois Herpes zoster is a viral disease that occurs incidence of HZ has been reported in
incapacitantes, et qui sont infrequently in young, healthy patients. patients with rheumatoid arthritis receiv-
souvent refractaires a tout However, its incidence rises sharply with ing weekly, low-dose methotrexate therapy
traitement. Bien que le zona
puisse repondre a l'acyclovir, les age from an estimated 0.5 cases/ 1000 in compared with the general population.8
considerations monetaires children to five to 10 cases/ 1000 in indi- These observations show that HZ out-
limitent l'utilite de ce viduals older than 80 years1 2; this phe- breaks are clearly dependent on the break-
medicament a un groupe nomenon has been attributed to an down of normal immune surveillance.
restreint de patients. La age-related decline in cellular immunity3
nevralgie postzosterienne Association with race, sex, ethnic back- Pathology of HZ
necessite une approche ground, or seasonal variations has not Acute varicella infection, usually a child-
holistique associee a une been reported for this disease.2 hood disease (chicken pox) begins with
pharmacotherapie comportant viral entry through the oral or respiratory
plusieurs classes de Ms Mamdani is a StaffPharmacist in the passages. Viremia and seeding of the skin
medicaments. Department ofPharmacy at the Vancouver General then follows, and as the primary infection
Cm fm idmn 1994;40321-332. Hospital. resolves, retrograde axonal transport of
did not receive treatment until 48 to lar complications otherwise affecting up to myocarditis
72 hours after onset of the rash. 50% of untreated individuals.24 -Pancreatitis
In addition, acyclovir caused a significant An important consideration related to -Esophagitis
- Enterocolitis
reduction in pain scores during the acute systemic acyclovir therapy is cost. Ten - Cystitis
stage (particularly among patients with days of oral therapy for HZ costs patients - Synovitis
severe pain), although a 6-month follow up approximately $250. The economic * Cutaneous dissemination
failed to show a sustained decrease in inci- impact of this drug must be weighed * Superinfection of
dence and severity of PHN.'9 In contrast, an against the morbidity of zoster in a partic- skin lesions
earlier study employing a 10-day course of ular patient population; hence, routine use
oral acyclovir at the same dose reported a of acyclovir in young and immunocompe- Adapted fram Ragozzino et a12
significant reduction in the incidence of tent individuals is unjustified. Conversely, and Carmichael.12
ANTICONVULSANIS (ORAL)
...........................................................................................................................................................................................................................
Carbamazepine 100 mg bid (initial) Useful for lancinating pain. Titrate dose
200-1200 mg/d (usual range) until effect or side effect occurs. Serum
level monitoring important for
carbamazepine, phenytoin, and
valproic acid
NEUROLEPICS (ORAL)
............................................................................................................................................................................................................................
TOPIAL
.............................................................................................................................................................. .....................................................................
Capsaicin 0.025% cream Apply 3 or 4 times daily Initial redness, burning, and stinging
(transient)
...........................................................................................................................................................................................................................
EMLA' cream (lidocaine 2.5% and Apply every 12 h
prilocaine 2.5%)
OTHER
...........................................................................................................................................................................................................................
Baclofen 5 mg tid (initial) Increase dose until effect or side effect
occurs
...........................................................................................................................................................................................................................
Mexiletin 200-900 mg/d Increase dose gradually. Gastrointestinal
side effects very common
.. .. .. t.. I1.
- - .1 I
COROiC nv7
TI/
CUNISITUO PYN KM Wr
TopicalSy
p-nmain'g
'
Lidocain,e and Bacdoed
M exile;tinj:1
I..... ......I.....
M KE
-%
;I ~~~~~I
CONSIDER SURGERY lisIS PHTSICALThE MAPY
(Dorsal woot. 'entry-zone lesion)
PSYC-H -pqchologic o;'pqc/aiaui s%ppon, 1015 - trancutaneotu electical nerve stimulation, OUNTERIRRTO -b&ik rubbinir ofpaiqp%l area often
Precede by q*zg
ap a4 coo&V4qsp1IAII ja cowhrp
'ayhraologic agent Mat haspwmvn ee iial edts*llvfid
Aated with pfrmissionfiom Cater -andPotn
330 Canadian Family Physician VOL 40: Februagy 1994
Conservative management of pa- 1O. LoeserJD. Herpes zoster and postherpetic
tients using good local skin care and neuralia- In: BonicajJ, LoeserJD, Chman CR,
over-the-counter analgesics might be the Fordyce WE, editrS. mem enofpai Vol 1.
best strategy in most HZ cases. Plladelphia: Lea and Febiger, 1990:.257-63.
Once PHN is established, a multimodal, 1 I. Portenoy RK, Duma C, Foley KM. Acute
multidisciplinary approach is indicated as herpetic and postherpetic neuralgia: clinical
with many other chronic pain syndromes. review and current management Ann Naa!
Amitriptyline, capsaicin, and possibly car- 1986;20:651-64.
banazepine (if pain has a shooting quality) 12. CannihaelJK. Treatment ofhexpes zoster and
are wise pharmacologic choices, at least in postherpetic neuralia. Am Fean Physicim 1991;44:
the preliminary phase of treatment. U 203-10.
13. Lewis GW. Zoster sine herpete. BAIJ 1958;
Acknowledgment 2:418-21.
I thank Dr Peter jewesson and Cindy Reesor, M 14. SatterthwaiteJR. Postherpetic neuralgia. In:
Phai for thirhelpfid comment dwigpmparation of Tollinson CD, editor. Handbook ofdffonipain
tkis manusr,pt. mnagemen. Baltimore: Williams and Wilkdns,
1989:460-71.
Requests for repnts to: Ms F.S. Mmani, 15. Strommen GL, Pucino F, Tight RR, Beck CL
Departnent ofPhamac~Vancoe Geal Hospital Human infection with herpes zoster. etiology,
855 W 12tl Ave, Venouve, BC V5Z IM9 pathophysiology, diagnosis, clinical course and
treatment. Pharmacoheapy 1988;8(1):52-68.
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