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Postherpetic neuralgia in the cancer patient

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Abstract

Postherpetic neuralgia (PHN) is the most common and devastating complication of acute herpes zoster (HZ). HZ occurs more frequently in the patient with human immunodeficiency virus (HIV) and with certain leukemias and lymphomas. PHN occurs more frequently in the elderly, in patients with severe pain in the acute stage, and in patients with lesions in the ophthalmic branch of the trigeminal nerve. Pain from PHN is often debilitating and difficult to treat. A wide variety of therapeutic approaches have been advocated over the years, but most are not very effective. Early aggressive treatment of HZ with antiviral drugs may be the most important step in prophylaxis against PHN. This article reviews the current knowledge of the pathogenesis and treatment of PHN.

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References and Recommended Reading

  1. Kost RG, Straus SE: Post-herpetic neuralgia-pathogenesis, treatment, and prevention. N Engl J Med 1996, 335:32–42. The latest comprehensive review of this disease.

    Article  CAS  PubMed  Google Scholar 

  2. McCrary ML, Severson J, Tyring SK: Varicella zoster virus. J Am Acad Dermatol 1999, 41:1–14.

    Article  CAS  PubMed  Google Scholar 

  3. Rusthoven JJ, Ahlgren P, Elhakim T, et al.: Varicella-zoster infections in adult cancer patients: a population study. Arch Intern Med 1988, 148:1561–1566.

    Article  CAS  PubMed  Google Scholar 

  4. Balfour HH: Varicella zoster infections in immunocompromised hosts: a review of the natural history and management. Am J Med 1988, 85:68–73.

    Article  PubMed  Google Scholar 

  5. Gershon AA, Raker R, Steinberg S, et al.: Antibody to varicellazoster virus in parturient women and their offspring during the first year of life. Pediatrics 1976, 58:692–696.

    CAS  PubMed  Google Scholar 

  6. Wallace MR, Hooper DG, Pyne JM, et al.: Varicella immunity and clinical diseases in HIV-infected adults. South Med J 1994, 87:74–76.

    Article  CAS  PubMed  Google Scholar 

  7. Stueiving JP, Hyams KC, Tuellar JE, Gray GC: The risk of measles, mumps, and varicella among young adults: a survey of US Navy and Marine Corps recruits. Am J Public Health 1993, 83:1717–1720.

    Article  Google Scholar 

  8. Arvin AM: Cell-mediated immunity to varicella zoster virus. J Infect Dis 1992, 166(suppl 1):35–41.

    Article  Google Scholar 

  9. Colebunders R, Mann JM, Francis H, et al.: Herpes zoster in African patients: a clinical predictor of human immunodeficiency virus infections. J Infect Dis 1988, 157:314–318.

    Article  CAS  PubMed  Google Scholar 

  10. Sokal JE, Firat D: Varicella-zoster infection in Hodgkin’s disease. Am J Med 1965, 39:452–463.

    Article  CAS  PubMed  Google Scholar 

  11. Schimpff S, Serpick A, Stoler B, et al.: Varicella-zoster infection in patients with cancer. Ann Intern Med 1972, 76:241–254.

    Article  CAS  PubMed  Google Scholar 

  12. Meyers JD, Flournoy N, Thomas ED: Cell-mediated immunity to varicella-zoster virus after bone marrow transplantation. J Infect Dis 1980, 141:479–487.

    Article  CAS  PubMed  Google Scholar 

  13. Locksley RM, Flournoy N, Sullivan KM, Meyers JD: Infection with varicella-zoster virus after bone marrow transplantation. J Infect Dis 1985, 152:1172–1181.

    Article  CAS  PubMed  Google Scholar 

  14. Ragozzino MW, Melton LJ 3rd, Kurland LT, et al.: Risk of cancer after herpes zoster: a population-based study. N Engl J Med 1982, 307:393–397.

    Article  CAS  PubMed  Google Scholar 

  15. Gilden DH, Dueland AN, Devlin ME, et al.: Varicella-zoster reactivation without rash. J Infect Dis 1992, 166(suppl 1):30–34.

    Article  Google Scholar 

  16. Seiler HE: A study of herpes zoster particularly in its relationship to chickenpox. J Hyg (Camb) 1949, 47:253–256.

    Article  CAS  Google Scholar 

  17. von Bokay J: Ueber den aetiologischen Zusammenhang der Varizellan mit gewissen Faellen von Herpes Zoster. Wien Klin Wochenschr 1909, 22:1323–1326.

    Google Scholar 

  18. Dworkin RH, Portenoy RK: Pain and its persistence in herpes zoster. Pain 1996, 67:241–251.

    Article  CAS  PubMed  Google Scholar 

  19. Dworkin RH, Portenoy RK: Proposed classification of herpes zoster pain. Lancet 1994, 343:1648.

    Article  CAS  PubMed  Google Scholar 

  20. Merskey H, Bogduk N, eds: Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, edn 2. Seattle: IASP Press; 1994.

    Google Scholar 

  21. Straus SE, Ostove JM, Inchauspe G, et al.: NIH conference: varicella-zoster virus infections: biology, natural history, treatment, and prevention. Ann Intern Med 1988, 108:221–237.

    Article  CAS  PubMed  Google Scholar 

  22. Crooks RJ, Jones DA, Fiddian AP: Zoster-associated chronic pain: an overview of clinical trials with acyclovir. Scand J Infect Dis 1991, 78(suppl):62–68.

    Google Scholar 

  23. de Moragas JM, Kierland RR: The outcome of patients with herpes zoster. Arch Dermatol 1957, 75:193–196.

    Article  Google Scholar 

  24. Harding SP, Lipton JR, Wells JCD: Natural history of herpes zoster opthalmicus: predictors of postherpetic neuralgia and ocular involvement. Br J Opthalmol 1987, 71:353–358.

    Article  CAS  Google Scholar 

  25. Choo PW, Galil K, Donahue JG, et al.: Risk factors for postherpetic neuralgia. Arch Intern Med 1997, 157:1217–1224.

    Article  CAS  PubMed  Google Scholar 

  26. Hope-Simpson RE: The nature of herpes-zoster: a long term study and new hypothesis. Proc R Soc London 1965, 58:9–20.

    CAS  Google Scholar 

  27. Bhala BB, Ramamoorthy C, Bowsher D, Yelnoorker KN: Shingles and postherpetic neuralgia. Clin J Pain 1988, 4:169–174.

    Article  Google Scholar 

  28. Bowsher D: Sensory change in postherpetic neuralgia. In Herpes Zoster and Postherpetic Neuralgia. Edited by Watson CPN. Amsterdam: Elsevier; 1993:97–107.

    Google Scholar 

  29. Portenoy RK, Duma C, Foley KM: Acute herpetic and postherpetic neuralgia: clinical review and current management. Ann Neurol 1986, 20:651–664.

    Article  CAS  PubMed  Google Scholar 

  30. Rowbotham MC, Fields HL: Postherpetic neuralgia: the relation of pain complaint, sensory disturbance, and skin temperature. Pain 1989, 39:129–144.

    Article  CAS  PubMed  Google Scholar 

  31. Graff-Radford SB, Kames LD, Naliboff BD: Measures of psychological adjustment and perception of pain in postherpetic neuralgia and trigeminal neuralgia. Clin J Pain 1986, 2:55–58.

    Article  Google Scholar 

  32. Watson CPN, Evans RJ, Watt VR, Birkett N: Postherpetic neuralgia: further post-mortem studies of cases with and without pain. Pain 1991, 44:105–117.

    Article  CAS  PubMed  Google Scholar 

  33. Wall PD, Gutnick M: Ongoing activity in peripheral nerves. Exp Neurol 1974, 43:580–593.

    Article  CAS  PubMed  Google Scholar 

  34. Watson CP, Morshead C, Van der Kooy D, et al.: Post-herpetic neuralgia: post-mortem analysis of a case. Pain 1988, 34:129–138.

    Article  CAS  PubMed  Google Scholar 

  35. Zacks SI, Langfitt TW, Elliott FA: Herpetic neuritis: a light and electronmicroscopic study. Neurology 1964, 14:744–750.

    Article  CAS  PubMed  Google Scholar 

  36. Vafai A, Wellish M, Gilden DH: Expression of varicella-zoster virus in blood mononuclear cells of patients with postherpetic neuralgia. Proc Natl Acad Sci U S A 1988, 85:2767–2770.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  37. Gilden DHJ, Devlin M, Wellish M, et al.: Persistence of varicella-zoster virus DNA in blood mononuclear cells of patients with varicella or zoster. Virus Genes 1988, 2:299–305.

    Article  Google Scholar 

  38. Cohen JI, Brunell PA, Straus SE, Krause PR: Recent advances in varicella-zoster virus infection. Ann Intern Med 1999, 130:922–932.

    Article  CAS  PubMed  Google Scholar 

  39. Elliott KJ: Introduction-postherpetic neuralgia: a treatment dilemma. Cancer Invest 1997, 15:163–164.

    Article  CAS  PubMed  Google Scholar 

  40. Hanania MM, Brietstein D: Postherpetic neuralgia: a review. Cancer Invest 1997, 15:165–176.

    Article  CAS  PubMed  Google Scholar 

  41. Tyring S, Barbarash RA, Nahlik JE, et al.: Famciclovir for the treatment of acute herpes zoster: effects on acute disease and postherpetic neuralgia: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 1995, 123:89–96.

    Article  CAS  PubMed  Google Scholar 

  42. De Greef H: Famciclovir, a new oral antiherpes drug: results of the first controlled clinical study demonstrating its efficacy and safety in the treatment of uncomplicated herpes zoster in immunocompetent patients. Int J Antimicrobial Agents 1995, 4:241–246.

    Google Scholar 

  43. Beutner KR, Friedman DJ, Forszpaniak C, et al.: Valacyclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrobial Agents Chemother 1995, 39:1546–1553.

    Article  CAS  Google Scholar 

  44. Wood MJ, Johnson RW, McKendrick MW, et al.: 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, 330:896–900.

    Article  CAS  PubMed  Google Scholar 

  45. Hayward A, Villaneuba E, Cosyns M, Levin M: Varicella-zoster virus (VZV) specific cytotoxicity after immunization with live attenuated varicella vaccine. Vaccine 1992, 10:1007–1014.

    Article  Google Scholar 

  46. Liang MG, Heidleberg KA, Jacobson RM, McEvoy MT: Herpes zoster after varicella immunization. J Am Acad Dermatol 1998, 38:761–763.

    Article  CAS  PubMed  Google Scholar 

  47. Watson CPN, Evans RJ, Reed K, et al.: Amitriptyline versus placebo in postherpetic neuralgia. Neurology 1982, 32:671–673.

    Article  CAS  PubMed  Google Scholar 

  48. Watson CP, Evans RJ: A comparative trial of amitriptyline and zimelidine in postherpetic neuralgia. Pain 1985, 23:387–394.

    Article  CAS  PubMed  Google Scholar 

  49. Max MB, Schafer SC, Culnane M, et al.: Amitriptyline, but not lorazepam, relieves postherpetic neuralgia. Neurology 1988, 38:1427–1432.

    Article  CAS  PubMed  Google Scholar 

  50. Watson CPN, Chipman M, Reed K, et al.: Amitriptyline versus maprotiline in postherpetic neuralgia; a randomized, double-blind, crossover trial. Pain 1992, 48:29–36.

    Article  CAS  PubMed  Google Scholar 

  51. Kishore-Kumar R, Max MB, Schafer SC, et al.: Desipramine relieves postherpetic neuralgia. Clin Pharmacol Ther 1990, 47:305–312.

    Article  CAS  PubMed  Google Scholar 

  52. Watson CPN: The treatment of postherpetic neuralgia. Neurology 1995, 45(suppl 8):58–60.

    Article  Google Scholar 

  53. Watson CN, Vernich L, Chipman M, Reed K: Nortriptyline versus amitriptyline in postherpetic neuralgia; a randomized trial. Neurology 1998, 51:1166–1171. Compared the current standard of treatment drug, amitriptyline, with a similar drug with fewer side effects and found it to be of equal efficacy.

    Article  CAS  PubMed  Google Scholar 

  54. Kishore-Kumar R, Schafer SC, Lawlor BA, et al.: Single doses of the serotonin agonist buspirone and m-chlorophenylpiperazine do not relieve neuropathic pain. Pain 1989, 37:223–227.

    Article  CAS  PubMed  Google Scholar 

  55. Davidoff G, Glarracini M, Roth E, et al.: Trazodone hydrochloride in the treatment of dysesthetic pain in trauma myelopathy: a randomized, double-blind placebo-controlled study. Pain 1987, 29:151–162.

    Article  CAS  PubMed  Google Scholar 

  56. Watson CPN: The medical treatment of postherpetic neuralgia: antidepressants, other therapies, and practical guidelines for management. In Herpes Zoster and Postherpetic Neuralgia. Edited by Watson CPN. Amsterdam: Elsevier; 1993:205–219.

    Google Scholar 

  57. Swerdlow M: Anticonvulsant drugs and chronic pain. Clin Neuropharmacol 1984, 7:51–82.

    Article  CAS  PubMed  Google Scholar 

  58. Killian JM, Fromm GH: Carbamazepine in the treatment of neuralgia. Arch Neurol 1968, 19:129–136.

    Article  CAS  PubMed  Google Scholar 

  59. Gerson GR, Jones RB, Luscombe DK: Studies on the concomitant use of carbamazepine and clomipramine for the relief of post-herpetic neuralgia. Postgrad Med J 1977, 53(suppl4):104–109.

    PubMed  Google Scholar 

  60. Rowbotham M, Harden N, Stacey B, et al.: Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled study. JAMA 1998, 21:1837–1842. This study supports the use of gabapentin, an anticonvulsant medication, which has demonstrated some usefulness (partial relief) in the treatment of PHN pain, without serious side effects.

    Article  Google Scholar 

  61. Dejgard A, Petersen P, Kastrup J: Mexiletine for the treatment of chronic, painful diabetic neuropathy. Lancet 1988, 1:9–11.

    Article  CAS  PubMed  Google Scholar 

  62. Max MB, Schafer SC, Culnane M, et al.: Association of pain relief with drug side effects in postherpetic neuralgia: a single-dose study of clonidine, codeine, ibuprofen, and placebo. Clin Pharmacol Ther 1988, 43:363–371.

    Article  CAS  PubMed  Google Scholar 

  63. de Benedittis G, Lorenzetti A: Topical aspirin/diethyl ether mixture versus indomethacin and diclofenac ether mixtures for acute herpetic neuralgia and postherpetic neuralgia: a double-blind crossover placebo-controlled study. Pain 1996, 65:45–51.

    Article  CAS  PubMed  Google Scholar 

  64. Rowbotham M, Reisner-Keller LA, Fields HL: Both intravenous lidocaine and morphine reduce pain of postherpetic neuralgia. Neurology 1991, 41:1024–1028.

    Article  CAS  PubMed  Google Scholar 

  65. Dellemijn PLI, Vanneste JAL: Randomised double-blind activeplacebo controlled cross over trial of intravenous fentanyl in neuropathic pain. Lancet 1997, 349:753–758.

    Article  CAS  PubMed  Google Scholar 

  66. Watson CPN, Babul N: Efficacy of oxycodone in neuropathic pain: a randomized trial in postherpetic neuralgia. Neurology 1998, 50:1837–1841.

    Article  CAS  PubMed  Google Scholar 

  67. Pappagallo M, Campbell JN: Chronic opioid therapy as alternative treatment for post-herpetic neuralgia. Ann Neurol 1994, 35(suppl):54–56.

    Article  Google Scholar 

  68. Taub A: Relief of postherpetic neuralgia with psychotropic drugs. J Neurosurg 1973, 39:235–239.

    Article  CAS  PubMed  Google Scholar 

  69. Merskey H, Hester RA: The treatment of chronic pain with psychotropic drugs. Postgrad Med J 1972, 48:594–598.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  70. Watson CP, Evans RJ, Watt VR: Post-herpetic neuralgia and topical capsaicin. Pain 1988, 33:333–340.

    Article  CAS  PubMed  Google Scholar 

  71. Bernstein JE, Bickers DR, Dahl MV, Roshal JY: Treatment of chronic postherpetic neuralgia with topical capsaicin: a preliminary study. J Am Acad Dermatol 1987, 17:93–96.

    Article  CAS  PubMed  Google Scholar 

  72. Watson CPN, Tyler KL, Bickers DR, et al.: A randomized vehicle-controlled trial of topical capsaicin in the treatment of post herpetic neuralgia. Clin Ther 1993, 15:510–526.

    CAS  PubMed  Google Scholar 

  73. Rowbotham MC, Davies PS, Fields HL: Topical lidocaine gel relieves postherpetic neuralgia. Ann Neurol 1995, 37:246–253.

    Article  CAS  PubMed  Google Scholar 

  74. Epstein E: Triamcinolone-procaine in the treatment of zoster and post zoster neuralgia. California Med 1971, 115:6–10.

    PubMed Central  CAS  PubMed  Google Scholar 

  75. Ferrara RJ: Herpes zoster: a combined therapy regiment. Cutis 1976, 17:103–109.

    CAS  PubMed  Google Scholar 

  76. Straus SE, Ostrove JM, Inchauspe G: Varicella-zoster virus infections: biology, natural history, treatment and prevention. Ann Intern Med 1988, 108:221–237.

    Article  CAS  PubMed  Google Scholar 

  77. Wood MJ, Johnson RW, McKendrick MW, et al.: A randomized trial of acyclovir for 7 to 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med 1994, 330:896–900.

    Article  CAS  PubMed  Google Scholar 

  78. Benoldi D, Minizzi S, Zucchi A, et al.: Prevention of post-herpetic neuralgia. Evaluation of treatment with oral prednisolone, oral acyclovir and radiotherapy. Pharmacol Ther 1990, 30:288–293.

    Google Scholar 

  79. Forrest JB: Management of chronic dorsal root pain with epidural steroid. Can Anaesth Soc J 1978, 25:218–225.

    Article  CAS  PubMed  Google Scholar 

  80. Forrest JB: The response to epidural steroid injections in chronic dorsal root pain. Can Anaesth Soc J 1980, 27:40.

    Article  CAS  PubMed  Google Scholar 

  81. Schreuder M: Pain relief in herpes zoster. S Afr Med J 1983, 63:820.

    CAS  PubMed  Google Scholar 

  82. Loeser JD: Herpes zoster and postherpetic neuralgia: review article. Pain 1986, 25:149–164.

    Article  CAS  PubMed  Google Scholar 

  83. Yamashiro H, Ogata R, Kawahara K: A complete relief of intractable postherpetic neuralgia with intrathecal methylprednisolone acetate. Masui 1990, 39:106–110.

    CAS  PubMed  Google Scholar 

  84. Kikuchi A, Kotani N, Sato T, et al.: Comparative therapeutic evaluation of intrathecal versus epidural methylprednisolone for long-term analgesia with intractable postherpetic neuralgia. Reg Anesth and Pain Med 1999, 24:287–293. A controversial article that investigates a novel way to treat refractory cases.

    CAS  Google Scholar 

  85. Hogan QH: The sympathetic nervous system in post-herpetic neuralgia. Reg Anesth 1993, 18:271–273.

    CAS  PubMed  Google Scholar 

  86. Watson CPN: Post herpetic neuralgia. Neurol Clin 1989, 7:231–248.

    CAS  PubMed  Google Scholar 

  87. Long DM: External electrical stimulation as a treatment of chronic pain. Minnesota Med 1974, 57:195–198.

    CAS  PubMed  Google Scholar 

  88. Nathan PW, Wall PD: Treatment of post-herpetic neuralgia by prolonged electrical stimulation. BMJ 1974, 3:645–647.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  89. Taverner D: Alleviation of post-herpetic neuralgia. Lancet 1960, 2:671–673.

    Article  Google Scholar 

  90. Manchikanti L: Management of postherpetic neuralgia. Anesthesiology Rev 1990, 17:25–34.

    Google Scholar 

  91. Shimoji K, Hokari T, Kano T, et al.: Management of intractable pain with percutaneous epidural spinal cord stimulation: differences in pain-relieving effects among diseases and sites of pain. Anesth Analg 1993, 77:110–116.

    Article  CAS  PubMed  Google Scholar 

  92. Portenoy RK, Duma C, Foley KM: Acute herpetic and postherpetic neuralgia: clinical review and current management. Ann Neurol 1986, 20:651–654.

    Article  CAS  PubMed  Google Scholar 

  93. Crue BL, Jr.: Neuritis, neuropathy, and neuralgia. In Handbook of Pain Management, edn 2. Edited by Tollison CD. Baltimore: Williams & Wilkins; 1994:377–385.

    Google Scholar 

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  1. Department of Anesthesiology, Northwestern University Medical School, 251 East Huron Street, 60611, Chicago, IL, USA

    Edwin Lojeski DO & Rom A. Stevens MD

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  1. Edwin Lojeski DO
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Lojeski, E., Stevens, R.A. Postherpetic neuralgia in the cancer patient. Current Review of Pain 4, 219–226 (2000). https://doi.org/10.1007/s11916-000-0083-6

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