Prevention and Management of Pain Associated with Herpes Zoster

By age 15, over 90% of Americans are infected with the varicella zoster virus (VZV). Reactivation of this virus, herpes zoster or shingles, afflicts approximately 10–20% of the general population at least once during their lifetime. VZV reactivation most commonly involves the mid-to-lower thoracic, ophthalmic, or upper lumbar derma-tomes. The rash initially appears as discrete patches of erythema which then progresses to grouped vesicles. Acute herpetic neuralgia occurs before and during the rash. High-dose prednisone, if started within 48 hours of rash onset, has reduced the morbidity of acute herpetic neuralgia. Pain lasting for greater than 30 days after rash appearance is generally referred to as postherpetic neuralgia. Nearly 75% of patients afflicted with herpes zoster will require follow up physician visits for management of postherpetic neuralgia. Three antiviral agents available in the United States for the treatment of herpes zoster-acyclovir, famciclovir, and valacyclovir-may dramatically reduce the incidence and duration of postherpetic neuralgia if given within the first 72 hours of the onset of the rash. Despite appropriate therapy with antiviral agents and corticosteroids, many people still suffer from postherpetic neuralgia which can often be successfully treated with tricyclic antidepressants and/or anticonvulsant agents as well as topical agents such as capsaicin cream.