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10.02.2014

Coping with herpes and postherpetic neuralgia, cold sore remedy - Try Out

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Prevelance of postherpetic neuralgia after a first episode of herpes zoster: prospective study with long term follow up. Oral acyclovir therapy accelerates pain resolution in patients with herpes zoster: a meta-analysis of placebo-controlled trials. Famciclovir for the treatment of acute herpes zoster: effects on acute disease and postherpetic neuralgia. Antiviral therapy for herpes zoster: randomized, controlled clinical trial of valacyclovir and famciclovir therapy in immunocompetent patients 50 years and older.
A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. The effect of treating herpes zoster with oral acyclovir in preventing postherpetic neuralgia. The effects of pre-emptive treatment of postherpetic neuralgia with amitriptyline: a randomized, double-blind, placebo-controlled trial. Treatments for postherpetic neuralgia—a systematic review of randomized controlled trials. Gabapentin in postherpetic neuralgia: a randomised, double blind, placebo controlled study. Opioids versus antidepressants in postherpetic neuralgia: a randomized, placebo-controlled trial. The lidocaine patch 5% effectively treats all neuropathic pain qualities: results of a randomized, double-blind, vehicle-controlled, 3-week efficacy study with use of the neuropathic pain scale. A randomized vehicle-controlled trial of topical capsaicin in the treatment of postherpetic neuralgia. History of Present Illness: Patient has noticed a three day history of decreased visual acuity OD, right periorbital headache, and right periorbital rash. External and anterior segment examination: Cornea was clear with no dedritic nor pseudodentritic forms. B: Crops of vessicular lesions in V2 distribution well delineated on upper lip and oropharynx. Of interest in this patient is the presence of ectropion secondary to a significant amount of localized induration and edema. Course: The patient did have some persisting pain and parasthesias in the V2 distribution even after resolution of the skin lesions. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). Scientists don’t understand why the varicella virus reactivates in some people and not in others. When new blisters are forming and old blisters are still healing, shingles is contagious to people who have never had chickenpox. According to the Centers for Disease Control and Prevention, nearly one in three people in America, which equals about 1 million people, will develop shingles.
Peters recalled a trying time just before she developed shingles when her grandfather and uncle were gravely ill at the same time.
A bookkeeper at a Houston photolithography business then, she drove to Beaumont four days a week after getting off work to spend a few hours with her hospitalized grandfather before heading back. One employee, who asked for anonymity, said 27 years after shingles and its complications left her hospitalized for three weeks, pain continues to be part of her life. In 1985, shingles swept across the right side of her face from her forehead into her eye and ear and down to her neck. If the shingles virus spreads to facial nerves, and a rash occurs on the ear or in the mouth, it can cause Ramsay Hunt syndrome.
In addition, herpes zoster can affect the brain when it causes inflammation of the membrane in and around the brain. The initial signs and symptoms of shingles usually appear on a small part of one side of the body. Patients are usually given antiviral drugs, such as acyclovir and valacyclovir, and drugs that help lessen nerve pain, such as Gabepentin, Neurontin or Gralise. Blisters from small bumps will fill with pus and break open before they start to crust over in about a week.
For most patients, pain and itching usually wear off within weeks after the shingles rash clears.


Silva said tricyclic antidepressant was originally intended for depression, but it also relieves post-herpetic neuralgia. Silva urges people to keep their immunity strong whether or not they have the vaccine option and to be on the alert. Preherpetic neuralgia, including burning, itching, or hypersensitivity localized to the affected dermatome, can occur with the prodromal illness. In cases where the diagnosis is in doubt, polymerase chain reaction (PCR) techniques are the most sensitive and specific diagnostic tests; however, these techniques are not widely available. The most recent meta-analysis15 of five placebo-controlled trials comparing acyclovir with placebo in the prevention of postherpetic neuralgia reported a number needed to treat (NNT) of 6.3 to reduce the incidence of pain at six months. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This was secondary to suspected bacterial cellulitis superimposed on the affected area, as can often occur with zoster skin lesions. An estimated 1 million cases occur in the United States each year, and increasing age is the primary risk factor.
These symptoms may occur one to five days before the appearance of the rash.4 Abnormal skin sensations range from itching and burning to hyperesthesia and severe pain. It usually affects children with symptoms such as a mild headache and fever, body weakness, and blistery rash on the skin and sometimes mucous membranes. Some patients have agonizing complications, including extreme pain and itching, which can last long after the rash clears up.
Scientists discovered that after people have had chickenpox, the varicella virus stays in their dorsal root ganglia – nerve bundles outside the brain and spine that send sensory information from the skin to the brain.
The virus in this form is called herpes zoster, which runs amok in the ganglion and its linked nerves. Symptoms of this syndrome include severe pain in the ear, hearing loss and vertigo, and can lead to the temporary or permanent paralysis of facial nerves. But about one in five patients, especially older adults, develop post-herpetic pain and itch, which last for months, years or even a lifetime, and is difficult to manage, doctors say.
Silva recommends anti-itch remedies including antihistamine medication and cool compresses. In 2008, a national panel of experts on immunizations at the Centers for Disease Control and Prevention recommended its use for all adults 60 and older. Subscribers to the city-sponsored Medicare Advantage plans are covered with a $45 copayment.
The role of the varicella vaccine in preventing herpes zoster is uncertain, but is being studied.
Before a recommendation to vaccinate middle-aged adults is made, future risk of herpes zoster in previously vaccinated adults and the cost-effectiveness of a vaccination program need to be evaluated. There is only one trial10 examining the effect of famciclovir on postherpetic neuralgia; it concluded that seven days of famciclovir had no effect on the overall incidence of postherpetic neuralgia but did reduce its duration. The range of effective dosages for desipramine was 12.5 to 250 mg daily, with the average effective dosage being 167 mg daily. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
Postherpetic pain may take several forms, including allodynia (nonpainful stimulus perceived as painful), hyperpathia (slightly painful stimulus perceived as very painful), and dysesthesia (abnormal sensation with no stimuli).8Women are at greater risk of postherpetic neuralgia. In less than two weeks, when the discolored area morphed into an 8-inch patch of lesions rupturing with pus and spreading from her hip to her leg, Peters finally realized something was wrong. Her doctor treated her for poison ivy allergy and gave her a penicillin shot that caused violent reactions. While some patients are tormented by pain and itching at the same time, for others, itching starts when pain begins to fade. There is evidence to support using antiviral therapy and possibly low-dose tricyclic antidepressants to prevent postherpetic neuralgia. The skin eruption usually is limited to a single dermatome; the most commonly involved dermatomes are the thoracolumbar region and the face. Viral culture has a low sensitivity because the herpes virus is labile and difficult to recover from the vesicular fluid.
The range of effective dosages for amitriptyline was 12.5 to 150 mg daily with the average dosage being 70 mg daily. However, prompt treatment with ocular lubrication, oral acyclovir for the zoster, and oral cephalexin (Keflex®) for the cellulitis resulted in resolution without corneal damage nor permanent ectropion (Figure 2).


Lesions progress to clear vesicles that become cloudy within three to five days, then crust and heal within two to four weeks.
There is good evidence that treating herpes zoster with antiviral medication is beneficial, particularly in patients older than 50 years with severe outbreaks.
The most common side effects were dry mouth, constipation, and sedation, although they were not a major problem at the relatively low doses needed for effect. Adjunct medications, including opioid analgesics, tricyclic antidepressants, or corticosteroids, may relieve the pain associated with acute herpes zoster.
Superimposed bacterial skin infections with streptococci and staphylococci should be treated with appropriate oral antibiotics. The average wholesale cost of Zostavax is $194 per dose,13 and many insurance plans do not cover it. The initial rash is erythematous, with multiple maculopapular lesions that subsequently become vesicular (Figure 1). There was no significant difference in benefits when maprotiline (Ludiomil) was compared with amitriptyline, but there was a higher incidence of side effects with maprotiline.ANTICONVULSANTSTwo randomized controlled trials18,19 support the use of gabapentin (Neurontin) to treat postherpetic neuralgia with an NNT of 3 in one trial and 5 in the other. In this particular patient, there was no evidence of the corneal involvement nor intraocular inflammation that can sometimes be seen with herpes zoster. There is conflicting evidence that antiviral therapy during the acute phase prevents postherpetic neuralgia.
In patients who develop postherpetic neuralgia, there is good evidence to support treatment with gabapentin and tricyclic antidepressants. Postherpetic neuralgia in the cutaneous nerve distribution may last from 30 days to more than six months after the lesions have healed.
The vaccine must be frozen, and in-office administration requires a monitored, temperature-controlled freezer. Cost to the patient will be higher, depending on prescription filling fee.There are no data examining the effect of antiviral treatment given more than 72 hours after the onset of the herpes zoster rash. Evidence supports treating postherpetic neuralgia with tricyclic antidepressants, gabapentin, pregabalin, long-acting opioids, or tramadol; moderate evidence supports the use of capsaicin cream or a lidocaine patch as a second-line agent. Common side effects included constipation, sedation, and nausea.20 Another study21 showed that morphine (MS Contin) and nortriptyline (Pamelor) provided better and equivalent pain relief, respectively, than placebo (decrease in baseline pain by 33 percent). Immunization to prevent herpes zoster and postherpetic neuralgia is recommended for most adults 60 years and older. One study12 found that patients treated with corticosteroids and acyclovir had a greater reduction in pain on days 7 and 14, but at day 21 there was no difference.
Herpes zoster (shingles) presents as a painful vesicular rash and is caused by reactivation of the varicella-zoster virus within the dorsal root or cranial nerve ganglia.
The incidence of postherpetic neuralgia increases with age and is uncommon in patients younger than 60 years (Table 13). The second study13 found that corticosteroids combined with acyclovir did not affect cutaneous healing but did result in a significant benefit in quality of life at day 30, including less time returning to normal activity and uninterrupted sleep. Herpes zoster lesions can become secondarily infected with staphylococci or streptococci, and cellulitis may develop. Many patients with chronic diseases such as diabetes, renal insufficiency, and hypertension were excluded from this study, limiting its applicability. Burning or stinging was the main side effect; this diminished after the first week with regular application of the cream.
Herpes zoster involving the ophthalmic division of the trigeminal nerve can lead to ocular complications and visual loss, so referral to an ophthalmologist is recommended.
Only patients who have postherpetic neuralgia unresponsive to oral and topical therapy should be considered for intrathecal methylprednisolone. However, it should be used only if other agents have been ineffective.20Other treatments for postherpetic neuralgia have been investigated, but not all are effective. Aspirin cream has been helpful in a few small studies, but the benefit is not considered significant.20 No recommendations can be made for the anticonvulsants valproate (Depakote)19 and carbamazepine (Tegretol)20 because of limited data.
Anesthetic agents such as N-methyl-d-aspartate receptor antagonists play a role in processing pain signals and could potentially benefit patients with postherpetic neuralgia.



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