Data-Medicos 
Dermagic/Express No. 75 
22 Septiembre 1.999. 22 September 1.999. 

~ Zoster y Dolor ~ 
~ Zoster and Pain ~ 


EDITORIAL ESPANOL 
================= 
Hola amigos de la red, DERMAGIC de nuevo con ustedes. El tema de hoy: ZOSTER Y DOLOR. Quiza el HERPES ZOSTER sea una de las enfermedades mas comunes donde los pacientes van a la "BRUJA",, quien muy inteligentemente le dice: " colgare una rana en una cuerda y cuando se seque habras curado de tu enfermedad",, CLARO ,,,el curso clinico del hepes zoster es de UNOS 15 dias...el tiempo en que tarda en secar la rana... EXITO total para la BRUJA !!!,,,, PERO 
y que hacemos con la NEURALGIA POSTHERPETICA,,,, ??? en este caso hay que ser mas inteligente que la BRUJA, pues muchos tratamientos has sido descritos y es un reto TOTAL para cualquier dermatologo quitar el DOLOR postherpetico 
En estas 80 referencias bibliograficas se describen algunos de ellos, escojan ustedes el que les parezca mejor !!!. 
........... y Pendiente con la bruja !!! 

Saludos a todos !!! 

PROXIMA EDICION: ERITEMA DISCROMICO PERSTANS O LIQUEN PLANO, 
....una diferente entidad ???? o la misma ??? 

Dr. Jose Lapenta R.,,, 

EDITORIAL ENGLISH 
================= 
Hello friends of the net, DERMAGIC again with you. Today's topic: ZOSTER AND PAIN. 
The HERPES ZOSTER are maybe one of the illnesses but common where the patients go to the " WITCH " who very smartly tells him: " I will hang a frog in a rope and when she dries off you will have cured of your illness", OF COURSE, ,the clinical course of the hepes zoster is of ABOUT 15 days...the time in that it takes in drying the frog... Total SUCCESS for the WITCH!!!, BUT.. and what we will make with the POSTHERPETIC NEURALGIA ??, in this case it is necessary to be but intelligent than the WITCH, because many treatments have been described and it is a TOTAL challenge for any dermatologist to remove the POSTHERPETIC PAIN. 
In these 80 bibliographical references some of them are described, you choose the one that seems better!!!. 
.......... And be care with the witch !!! 

NEXT EDITION: ERYTHEMA DISCHROMICUN PERSTANS or LICHEN PLANUS 
.......a different entity ???? or the same one ??? 

Greetings to ALL, !! 
Dr. Jose Lapenta R.,,, 
=================================================================== 
REFERENCIAS BIBLIOGRAFICAS / BIBLIOGRAPHICAL REFERENCES 
=================================================================== 
1.) Comparative therapeutic evaluation of intrathecal versus epidural methylprednisolone for long-term analgesia in patients with intractable postherpetic neuralgia. 
2.) Patient-controlled epidural analgesia for postherpetic neuralgia in an HIV-infected patient as a therapeutic ambulatory modality. 
3.) A trial of intravenous lidocaine on the pain and allodynia of postherpetic neuralgia. 
4.) Pain and somatosensory dysfunction in acute herpes zoster. 
5.) Topical lidocaine patch relieves postherpetic neuralgia more effectively than a vehicle topical patch: results of an enriched enrollment study. 
6.) [Treatment of postherpetic neuralgia by topical application of prostaglandin E1-vaseline mixture--a single blind controlled clinical trial]. 
7.) Acute herpetic neuralgia and postherpetic neuralgia in the head and neck: response to gabapentin in five cases. 
8.) HLA-A33 and -B44 and susceptibility to postherpetic neuralgia (PHN). 
9.) Evaluation of analgesic effect of low-power He:Ne laser on postherpetic neuralgia using VAS and modified McGill pain questionnaire. 
10.) Iontophoretic vincristine in the treatment of postherpetic neuralgia: a double-blind, randomized, controlled trial. 
11.) Treatment of postherpetic neuralgia. 
12.) [Neuralgia and zovirax treatment of patients with herpes zoster]. 
13.) Follow-up of clinical efficacy of iontophoresis therapy for postherpetic neuralgia (PHN). 
14.) Effect of Ganoderma lucidum on postherpetic neuralgia. 
15.) Use of a live attenuated varicella vaccine to boost varicella-specific immune responses in seropositive people 55 years of age and older: duration of booster effect. 
17.) Postherpetic neuralgia: impact of famciclovir, age, rash severity, andacute pain in herpes zoster patients. 
18.) The identification of risk factors associated with persistent pain following herpes zoster. 
19.) Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial. 
20.) [Clinical course and treatment of herpetic trigeminal ganglionic neuropathy]. 
21.) Unilateral postherpetic neuralgia is associated with bilateral sensory neuron damage. 
22.) CSF and MRI findings in patients with acute herpes zoster. 
23.) In vitro activity of acetylsalicylic acid on replication of varicella-zoster virus. 
24.) Herpes zoster in children and adolescents. 
25.) Oral corticosteroids for pain associated with herpes zoster. 
26.) Toxic effects of capsaicin on keratinocytes and fibroblasts. 
27.) Gamma knife treatment of trigeminal neuralgia: clinical and electrophysiological study. 
28.) Nortriptyline versus amitriptyline in postherpetic neuralgia: a randomized trial. 
29.) [Lidocaine tape (Penles--a dressing tape based on 60% lidocaine-) reduces the pain of postherpetic neuralgia]. 
30.) Postherpetic neuralgia: irritable nociceptors and deafferentation. 
31.) The caudalis DREZ for facial pain. 
32.) DREZ coagulations for deafferentation pain related to spinal and peripheral nerve lesions: indication and results of 79 consecutive procedures. 
33.) Jaipur block in postherpetic neuralgia. 
34.) Efficacy of oxycodone in neuropathic pain: a randomized trial in postherpetic neuralgia. 
35.) Intracutaneous histamine injection can detect damage of cutaneous afferent fibres in postherpetic neuralgia. 
36.) The management of postherpetic neuralgia. 
37.) The "three-in-one block" for treatment of pain in a patient with acute herpes zoster infection. 
38.) Use of gabapentin in pain management. 
39.)Peppers and pain. The promise of capsaicin. 
40.) Economic evaluation of famciclovir in reducing the duration of postherpetic neuralgia. 
41.) The effects of pre-emptive treatment of postherpetic neuralgia with amitriptyline: a randomized, double-blind, placebo-controlled trial. 
42.) Persistence of varicella-zoster virus DNA in elderly patients with postherpetic 
neuralgia. 
43.) Risk factors for postherpetic neuralgia [see comments] 
44.) Deep brain stimulation for intractable pain: a 15-year experience. 
45.) [Treatment of post-herpes zoster pain with tramadol. Results of an open pilot study 
versus clomipramine with or without levomepromazine] 
46.) High-dose oral dextromethorphan versus placebo in painful diabetic neuropathy and postherpetic neuralgia. 
47.) Herpes zoster and postherpetic neuralgia. Optimal treatment. 
48.) The effect of treating herpes zoster with oral acyclovir in preventing 
postherpetic neuralgia. A meta-analysis. 
49.) A systematic review of antidepressants in neuropathic pain. 
50.) Pain and its persistence in herpes zoster. 
51.) [Interferon alpha 2b in pain caused by herpes zoster. Preliminary report] 
Interferon alpha 2b en el dolor por herpes zoster. Informe preliminar. 
52.) Chronic electrical stimulation of the gasserian ganglion for the relief of pain in a series of 34 patients. 
53.) Systemic corticosteroids do not prevent postherpetic neuralgia. 
54.) Prevention of post-herpetic neuralgia. Evaluation of treatment with oral prednisone, oral acyclovir, and radiotherapy. 
55.)Postherpetic neuralgia and systemic corticosteroid therapy. Efficacy and safety. 
56.) Argon laser induced cutaneous sensory and pain thresholds in post-herpetic neuralgia. Quantitative modulation by topical capsaicin. 
57.) Topical capsaicin treatment of chronic postherpetic neuralgia. 
58.) Treatment of chronic postherpetic neuralgia with topical capsaicin. A preliminary study. 
59.) Prednisolone does not prevent post-herpetic neuralgia. 
60.) Clinical experience with pimozide: emphasis on its use in postherpetic neuralgia. 
61.) Famciclovir for the treatment of acute herpes zoster: effects on acute disease and postherpetic neuralgia. A randomized, double-blind, placebo-controlled trial. Collaborative Famciclovir Herpes Zoster Study Group. 
62.) Peripheral blood mononuclear cells of the elderly contain varicella-zoster virus DNA. 
63.) Dehydroemetine therapy for herpes zoster. A comparison with corticosteroids. 
64.) A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster [see comments] 
65.) Early vidarabine therapy to control the complications of herpes zoster in immunosuppressed patients. 
66.) EMLA. A new and effective topical anesthetic [see comments] 
67.) Response of varicella zoster virus and herpes zoster to silver sulfadiazine. 
68.) Thalidomide: use and possible mode of action in reactional lepromatous leprosy and in various other conditions. 
69.) Administration of levodopa for relief of herpes zoster pain. 
70.) Treatment of zoster and postzoster neuralgia by the intralesional injection of triamcinolone: a computer analysis of 199 cases. 
71.) Epidural injection of local anesthetic and steroids for relief of pain secondary to herpes zoster. 
72.) Association of pain relief with drug side effects in postherpetic neuralgia: a single-dose study of clonidine, codeine, ibuprofen, and placebo. 
72.) Italian multicentric study on pain treatment with epidural spinal cord stimulation. 
73.) Postherpetic neuralgia: clinical experience with a conservative treatment. 
74.) Spinal cord stimulation (SCS) in the treatment of postherpetic pain. 
75.) Postherpetic neuralgia. 
76.) Treatment of post-herpetic neuralgia and acute herpetic pain with amitriptyline and perphenazine. 
77.) Nontraditional analgesics for the management of postherpetic neuralgia. 
78.) Efficacy of baclofen in trigeminal neuralgia and some other painful conditions. A clinical trial. 
79.) Epidural morphine and postherpetic neuralgia [letter] 
80.) Acupuncture and postherpetic neuralgia [letter] 
================================================================= 
1.) Comparative therapeutic evaluation of intrathecal versus epidural 
methylprednisolone for long-term analgesia in patients with intractable 
postherpetic neuralgia. 
================================================================= 
Reg Anesth Pain Med 1999 Jul-Aug;24(4):287-93 

Kikuchi A, Kotani N, Sato T, Takamura K, Sakai I, Matsuki A 
Department of Anesthesiology, University of Hirosaki School of Medicine, 
Japan. 

BACKGROUND AND OBJECTIVES The goal of this study was to evaluate the 
analgesic effects of intrathecal versus epidural methylprednisolone acetate 
(MPA) in patients with intractable postherpetic neuralgia (PHN). METHODS: 
We studied 25 patients with a duration of PHN of more than 1 year. The 
patients were randomly allocated to one of two groups: an intrathecal group 
(n = 13) and an epidural group (n = 12). Sixty milligrams of MPA was 
administered either into the intrathecal or the epidural space four times 
at 1-week intervals depending on the treatment group. Continuous and 
lancinating pain and allodynia were evaluated by a physician unaware of 
group assignment with a 10-cm visual analogue scale before treatment, at 
the end of treatment, and 1 and 24 weeks after treatment. In addition, 
cerebrospinal fluid (CSF) was obtained for measurement of interleukin 
(IL)-1beta, -6, and -8 and tumor necrosis factor-alpha before and 1 week 
after treatment. RESULTS: We found marked alleviation of continuous and 
lancinating pain and allodynia in the intrathecal group (P < .001). The 
improvements were much greater in the intrathecal group than in the 
epidural group at all time points after the end of treatment (P < .005). 
IL-8 in the CSF decreased significantly in the intrathecal group as 
compared to the epidural group at the l-week time point (P < .01), whereas 
the other cytokines were undetectable. CONCLUSIONS: Our results suggest the 
effectiveness of intrathecal as compared to epidural MPA for relieving the 
pain and allodynia associated with PHN. Also, our findings, together with 
the decrease in IL-8, may indicate that intrathecal MPA improves analgesia 
by decreasing an ongoing inflammatory reaction in the CSF. 

================================================================= 
2.) Patient-controlled epidural analgesia for postherpetic neuralgia in an 
HIV-infected patient as a therapeutic ambulatory modality. 
================================================================= 
Acta Anaesthesiol Sin 1998 Dec;36(4):235-9 

Kang FC, Chang PJ, Chen HP, Tsai YC 
Department of Anesthesiology, National Cheng Kung University, College of 
Medicine, Tainan, Taiwan, R.O.C. 

A 43-year-old HIV-positive male was referred to our pain clinic one month 
after his fourth attack of herpes zoster infection. He complained of 
intermittent intolerable sharp and lancinating pain accompanied by numbness 
over the inner aspect of the left upper extremity, left anterior chest wall 
and the back. Physical examination revealed allodynia over the left T1 and 
T2 dermatomes without any obvious skin lesion. The pain was treated with 
epidural block made possible by a retention epidural catheter placed via 
the T2-3 interspace. After the administration of 8 ml of 1% lidocaine in 
divided doses, the pain was completely relieved for 4 h without significant 
change of blood pressure or heart rate. A pump (Baxter API) for 
patient-controlled analgesia (PCA) filled with 0.08% bupivacaine was 
connected to the epidural catheter on the next day and programmed at a 
basal rate of 2 ml/h, PCA dose 2 ml, lockout interval 15 min, with an 
one-hour dose limit of 8 ml. He was instructed to report his condition by 
telephone every weekday. The pump was refilled with drug and the wound of 
catheter entry was checked and managed every 3 or 4 days. The epidural 
catheter was replaced every week. During treatment, the pain intensity was 
controlled in the range from 10 to 0-2 on the visual analogue scale. He was 
very satisfied with the treatment and reported only slight hypoesthesia 
over the left upper extremity in the early treatment period. Epidural PCA 
was discontinued after 28 days. He did not complain of pain thereafter but 
reported a slight numb sensation still over the lesion site for a period of 
time. In conclusion, postherpetic neuralgia in an HIV-infected man was 
successfully treated with ambulatory therapeutic modality of epidural PCA 
for 28 days. 

================================================================= 
3.) A trial of intravenous lidocaine on the pain and allodynia of 
postherpetic neuralgia. 
================================================================= 
J Pain Symptom Manage 1999 Jun;17(6):429-33 

Baranowski AP, De Courcey J, Bonello E 
Pain Management Centre, University College London Hospitals, United Kingdom. 

This study investigated the effect of intravenous lidocaine at two doses (1 
mg/kg and 5 mg/kg over 2 hours) and an intravenous saline placebo on the 
pain and allodynia of postherpetic neuralgia (PHN). Twenty-four patients 
were studied using a randomized, double-blind, within-patient crossover 
design. Each patient received normal saline, lidocaine 0.5 mg/kg/h, and 
lidocaine 2.5 mg/kg/h for a 2-h period. The McGill Pain Questionnaire Short 
Form, visual analogue scores (VAS), and area of allodynia were measured at 
intervals during the infusions. Free plasma lidocaine levels were also 
measured. The results were statistically analyzed using Student's t-test 
for paired data. The VAS for ongoing pain showed a significant reduction 
after all the infusions (P < 0.05). For dynamic pressure-provoked pain, the 
VAS was unaffected by placebo but showed a reduction at an equal level of 
significance with both lidocaine infusions (P < 0.05). The area of 
allodynia of PHN, as mapped by brush stroke, declined in association with 
intravenous lidocaine (0.5 mg/kg/h = P < 0.05; 2.5 mg/kg/h = P < 0.001). 
Placebo had no significant effect on the area of allodynia. These findings 
demonstrate a positive effect on pain and allodynia following a brief 
intravenous infusion of lidocaine. The higher dose infusion may produce 
plasma levels in the toxic range, with no significant clinical increase in 
response. 

================================================================= 
4.) Pain and somatosensory dysfunction in acute herpes zoster. 
================================================================= 
Clin J Pain 1999 Jun;15(2):78-84 

Haanpaa M, Laippala P, Nurmikko T 
Department of Neurology, Tampere University Hospital, Finland. 

OBJECTIVE: To determine the nature of sensory change and its association 
with pain and allodynia in acute herpes zoster. DESIGN: Prospective 
clinical study. PATIENTS: One hundred thirteen immunocompetent patients 
with acute herpes zoster. METHODS: Onset, intensity, and quality of pain 
and severity of rash were recorded. Quantitative somatosensory testing for 
tactile and thermal thresholds, qualitative pinprick testing, and testing 
of dynamic and static allodynia were performed within the affected 
dermatome, its mirror-image dermatome, and in an adjacent dermatome 
bilaterally. RESULTS: Acute pain was reported as severe in 50%, moderate in 
29%, mild in 12%, and absent in 9% of patients. Preherpetic pain (median = 
4 days, range = 1-60 days) was experienced by 71%. Mechanical allodynia, 
dynamic, static, or both, was found in 37% of patients and was noted to 
extend one or more dermatomes outside the rash in 12%. In the affected 
dermatomes, thresholds were elevated for warmth and cold, lowered for heat 
pain, and unchanged for touch when compared with the contralateral side. 
Logistic regression analyses showed that compression-evoked allodynia, 
brush-evoked allodynia, and the history of preherpetic pain were more 
frequently encountered in patients with severe pain. Sensory threshold 
changes were not associated with the severity of pain or rash or with the 
presence of allodynia. CONCLUSION: Pain, allodynia, and altered sensation 
are common features of acute herpes zoster. They are likely to result 
primarily from widespread neural inflammation within the affected afferent 
system. The sensory changes found in acute herpes zoster are different from 
those reported in published studies on postherpetic neuralgia and suggest 
sensitization phenomena and preservation of tactile functions rather than 
major neural damage. The exact mechanisms for acute herpes zoster pain, 
however, remain speculative. 

================================================================= 
5.) Topical lidocaine patch relieves postherpetic neuralgia more 
effectively than a vehicle topical patch: results of an enriched enrollment 
study. 
================================================================= 
Pain 1999 Apr;80(3):533-8 

Galer BS, Rowbotham MC, Perander J, Friedman E 
Institute for Education and Research in Pain Medicine and Palliative Care, 
Department of Pain Medicine and Palliative Care, Beth Israel Medical 
Centre, New York, NY 10003, USA. 

This study compared the efficacy of topical lidocaine patches versus 
vehicle (placebo) patches applied directly to the painful skin of subjects 
with postherpetic neuralgia (PHN) utilizing an 'enriched enrollment' study 
design. All subjects had been successfully treated with topical lidocaine 
patches on a regular basis for at least 1 month prior to study enrollment. 
Subjects were enrolled in a randomized, two-treatment period, 
vehicle-controlled, cross-over study. The primary efficacy variable was 
'time to exit'; subjects were allowed to exit either treatment period if 
their pain relief score decreased by 2 or more categories on a 6-item Pain 
Relief Scale for any 2 consecutive days. The median time to exit with the 
lidocaine patch phase was greater than 14 days, whereas the vehicle patch 
exit time was 3.8 days (P < 0.001). At study completion, 25/32 (78.1%) of 
subjects preferred the lidocaine patch treatment phase as compared with 
3/32 (9.4%) the placebo patch phase (P < 0.001). No statistical difference 
was noted between the active and placebo treatments with regards to side 
effects. Thus, topical lidocaine patch provides significantly more pain 
relief for PHN than does a vehicle patch. Topical lidocaine patch is a 
novel therapy for PHN that is effective, does not cause systemic side 
effects, and is simple to use. 

================================================================= 
6.) [Treatment of postherpetic neuralgia by topical application of 
prostaglandin E1-vaseline mixture--a single blind controlled clinical trial]. 
================================================================= 
Masui 1999 Mar;48(3):292-4 

Tamakawa S, Tsujimoto J, Iharada A, Ogawa H 
Department of Anesthesia, Rumoi Municipal Hospital. 

The purpose of this study is to find the most effective concentration of 
topical prostaglandin E1 (PGE1) to treat pain in postherpetic neuralgia 
(PHN). The concentrations of PGE1 dissolved in vaseline were 0 
microgram.g-1, 2 micrograms.g-1, 4 micrograms.g-1 and 8 micrograms.g-1. 
Visual analog scale (VAS) score was reduced after the ointment application 
in relation to the concentration of PGE1 with initial relief at 25 minutes 
and lasting for 5 hours. Three patients medicated with PGE1 8 
micrograms.g-1 and one patient medicated with 4 micrograms.g-1 complained 
of topical pain of the skin. Topical PGE1 dissolved in vaseline is an 
effective means of reducing pain due to PHN. Probably 4 micrograms.g-1 of 
the ointment is most useful to treat PHN. 

================================================================= 
7.) Acute herpetic neuralgia and postherpetic neuralgia in the head and 
neck: response to gabapentin in five cases. 
================================================================= 
Reg Anesth Pain Med 1999 Mar-Apr;24(2):170-4 

Filadora VA 2nd, Sist TC, Lema MJ 
Department of Anesthesiology and Pain Medicine, Roswell Cancer Institute, 
School of Medicine and Biomedical Sciences, State University of New York at 
Buffalo, 14263, USA. 

BACKGROUND AND OBJECTIVES: The clinical presentations and pharmacologic 
management of three patients with acute herpetic neuralgia (AHN) and two 
patients with postherpetic neuralgia (PHN), confined to the head and neck 
region, are described. METHODS: Two patients had pain in the ophthalmic 
division of the trigeminal nerve, two had pain confined to the C2-C4 
dermatomes, and one patient had C2 pain with radiating and referred pain to 
the second and third divisions of the trigeminal nerve. RESULTS: 
Gabapentin, an anticonvulsant drug, was effective in treating these 
patients, including the two cases of AHN. All patients reported complete 
pain relief after titration with gabapentin up to 1,800 mg/d. The patients 
noted a dose-dependent decrease in pain almost immediately after starting 
gabapentin. Specifically, reduction in the frequency and intensity of 
allodynia, burning pain, shooting pain, and throbbing pain were noted. None 
of the patients experienced side effects from the drug. CONCLUSIONS: In 
view of the results in these patients, blinded, controlled studies are 
needed to determine the efficacy of gabapentin for treating AHN and PHN. 

================================================================= 
8.) HLA-A33 and -B44 and susceptibility to postherpetic neuralgia (PHN). 
================================================================= 
Tissue Antigens 1999 Mar;53(3):263-8 

Ozawa A, Sasao Y, Iwashita K, Miyahara M, Sugai J, Iizuka M, Kawakubo Y, 
Ohkido M, Naruse T, Anzai T, Takashige N, Ando A, Inoko H 
Department of Dermatology, Tokai University School of Medicine, Isehara, 
Kanagawa, Japan. [email protected] 

HLA class I and class II alleles of 32 Japanese patients with postherpetic 
neuralgia (PHN) and 136 healthy controls were analyzed by serological 
(class I) and DNA (class II) typing for any significance in the 
susceptibility to varicella-zoster virus (VZV). We recognized positive 
associations of the development of PHN with the HLA class I antigens 
HLA-A33 and -B44, and the HLA-A33-B44 haplotype. This haplotype is tightly 
linked to DRB1*1302 in a Japanese healthy population. However, no 
significant association between PHN and HLA class II alleles was observed 
with no linkage of the HLA haplotype HLA-A33-B44 to HLA-DRB1*1302 in the 
patients with PHN. These findings suggest that HLA class I gene may 
genetically control the immune response against VZV in the pathogenesis of 
PHN. 

================================================================= 
9.) Evaluation of analgesic effect of low-power He:Ne laser on postherpetic 
neuralgia using VAS and modified McGill pain questionnaire. 
================================================================= 
J Clin Laser Med Surg 1991 Apr;9(2):121-6 

Iijima K, Shimoyama N, Shimoyama M, Mizuguchi T 
Department of Anesthesiology, Chiba University School of Medicine, Japan. 

In order to investigate the efficacy of low-power He:Ne laser in treatment 
of pain, we irradiated 18 outpatients with severe postherpetic neuralgia. 
The efficacy of the low-power laser treatment was evaluated using a 
four-grade estimation, visual analog scale (VAS), and modified McGill pain 
questionnaire (m-MPQ) after every 10 of as many as 50 irradiations. The 
efficacy rate using a four-grade estimation at the end of 50 treatments was 
94.4%. VAS decreased from 6.2 before irradiation therapy to 3.6 after 50 
treatments, and the degree of pain relief was reduced to 44.6% and 
correlated with the number of treatments. The total numbers of words and 
the total scores of the m-MPQ decreased as the number of treatments 
increased. No complications attributable to the laser therapy were 
observed. These results suggest that repeated irradiation with low-power 
He:Ne laser is an effective and safe therapy for postherpetic neuralgia. 

================================================================= 
10/) Iontophoretic vincristine in the treatment of postherpetic neuralgia: 
a double-blind, randomized, controlled trial. 
================================================================= 
J Pain Symptom Manage 1999 Mar;17(3):175-80 

Dowd NP, Day F, Timon D, Cunningham AJ, Brown L 
Department of Anesthesia and Pain Management, Beaumont Hospital, Dublin, 
Ireland. 

The effect of iontophoretic administration of vincristine in the treatment 
of postherpetic neuralgia (PHN) was investigated in a prospective, 
double-blind, placebo-controlled trial. Twenty patients with intercostal or 
lumbar PHN for more than 6 months that was unresponsive to conventional 
medical therapy were randomized to receive vincristine 0.01% (n = 11) or 
saline (n = 9), by iontophoresis over 1 hour daily for 20 days. 
Demographics and median duration of pain were similar in both groups. Pain 
scores decreased over the treatment period and were significantly lower on 
day 20 compared to baseline in both groups. Pain relief was described as 
moderate or greater in 40% of patients with vincristine and 55% of patients 
with placebo. There was no statistical difference an actual pain scores on 
day 20 between the two groups. Moderate or greater pain relief was 
maintained in 30% of patients with vincristine and 33% of patients with 
placebo at follow-up on day 90. We conclude that iontophoresed vincristine 
is no better than iontophoresed saline in the treatment of PHN. The 
maintained improvement in both groups at 3 months follow-up may reflect the 
natural history of PHN, or might possibly by related to a beneficial effect 
of iontophoresis. 

================================================================= 
11.) Treatment of postherpetic neuralgia. 
================================================================= 
J Am Pharm Assoc (Wash) 1999 Mar-Apr;39(2):217-21 

Menke JJ, Heins JR 
South Dakota State University, Brookings 57007-0099, USA. 
[email protected] 

OBJECTIVE: To review treatment options for postherpetic neuralgia (PHN). 
DATA SOURCES: Clinical literature selected by the authors accessed via 
MEDLINE. Search terms included postherpetic neuralgia, capsaicin, 
antidepressants, anticonvulsants, and lidocaine. STUDY SELECTION: 
Controlled trials relevant to PHN. DATA SYNTHESIS: Traditional analgesics 
offer little benefit for the treatment of PHN. The best results for pain 
relief have come from capsaicin and tricyclic antidepressants. 
Anticonvulsants have also been used, although the number of studies 
evaluating this is limited. More invasive therapies, such as transcutaneous 
electrical nerve stimulation and nerve blocks, can be considered if other 
therapies fail. CONCLUSION: Early diagnosis and treatment of herpes zoster 
may offer patients the best chance of preventing the development of PHN. 
However, if PHN does develop, the patient should seek treatment early for 
the best chance of pain relief. 

================================================================= 
12.) [Neuralgia and zovirax treatment of patients with herpes zoster]. 
================================================================= 
Ter Arkh 1998;70(12):63-5 

Dekonenko EP, Shishov AS, Kupriianova LV, Rudometov IuP, Bagrov FI 
AIM: To estimate the occurrence of postherpetic neuralgia (PHN) arising 
after acute period of herpes zoster (HZ) and determination of zovirax 
efficiency in PHN prevention. MATERIALS AND METHODS: Of a total of 102 
patients with HZ aged 17-89 years, 20 patients aged 26-83 years were given 
zovirax. RESULTS: Acute pain syndrome in PHN was observed in more that 
one-third of HZ patients. Patients over 60 years of age were more 
predisposed to PHN. Zovirax reduced the duration of acute rash and its 
healing, decreased the number of patients with zoster-associated pain and 
PHN patients. CONCLUSION: Zovirax is effective and safe in preventing PHN 
in HZ patients. 

================================================================= 
13.) Follow-up of clinical efficacy of iontophoresis therapy for 
postherpetic neuralgia (PHN). 
================================================================= 
J Dermatol 1999 Jan;26(1):1-10 

Ozawa A, Haruki Y, Iwashita K, Sasao Y, Miyahara M, Sugai J, Matsuyama T, 
Iizuka M, Kawakubo Y, Nakamori M, Ohkido M 
Department of Dermatology, Tokai University School of Medicine, Kanagawa, 
Japan. 

A great variety of therapies have been attempted for PHN, including 
pharmacotherapy and physical therapy. However, there has been no decisive 
treatment, and reports of the clinical efficacy of all available therapies 
have been rather controversial. Almost all studies conducted so far have 
looked only at short-term therapeutic efficacy, and only a few 
investigators have conducted long-term observations or studies on long-term 
outcome. We followed up the clinical efficacy of iontophoresis therapy 
using lidocaine and methylprednisolone in 197 PHN patients. Monitoring 
conducted for an average of 4 years after completion of the treatment 
showed that pain remained unchanged or improved compared to pain observed 
upon completion of the treatment in 90.4% of patients. Although 42.6% of 
patients were still continuing some treatment, 90.9% were found to be able 
to take care of themselves. Findings obtained were reviewed and discussed 
from various viewpoints. Our findings showed that iontophoresis therapy is 
not only effective at the end of the treatment, but its efficacy is 
maintained over a long period of time, indicating that it is clinically 
very useful for the treatment of PHN. 

================================================================= 
14.) Effect of Ganoderma lucidum on postherpetic neuralgia. 
================================================================= 
Am J Chin Med 1998;26(3-4):375-81 

Hijikata Y, Yamada S 
Tokyo Hijikata Clinic, Osaka, Japan. 

Administration of hot water soluble extracts of Ganoderma lucidum (GI) (36 
to 72 g dry weight/day) decreased pain dramatically in two patients with 
postherpetic neuralgia recalcitrant to standard therapy and two other 
patients with severe pain due to herpes zoster infection. 

================================================================= 
15.) Use of a live attenuated varicella vaccine to boost varicella-specific 
immune responses in seropositive people 55 years of age and older: duration 
of booster effect. 
================================================================= 
J Infect Dis 1998 Nov;178 Suppl 1:S109-12 

Levin MJ, Barber D, Goldblatt E, Jones M, LaFleur B, Chan C, Stinson D, 
Zerbe GO, Hayward AR 
Department of Pediatrics, University of Colorado School of Medicine, Denver 
80262, USA. 

Varicella-zoster virus (VZV)-specific T cell immunity was measured in 130 
persons > or = 55 years of age 6 years after they received a live 
attenuated VZV vaccine. Circulating T cells, which proliferated in vitro in 
response to VZV antigen, were enumerated (VZV responder cell frequency 
assay). Six years after the booster vaccination, the VZV-responding cell 
frequency (1/61,000 circulating cells) was still significantly (P < .05) 
improved over the baseline measurements (1/70,000) and appears to have 
diminished the expected decline in frequency as these vaccinees aged (to 
1/86,000). Ten herpes-zoster--like clinical events were recorded. Although 
the frequency of these events, approximately 1/100 patient-years, is within 
the expected range of such events for this age cohort, the number of 
lesions was small, there was very little pain, and there was no 
postherpetic neuralgia. These results support the development of a vaccine 
to prevent or attenuate herpes zoster. 

================================================================= 
16.) Postherpetic neuralgia: the importance of preventing this intractable 
end-stage disorder. 
================================================================= 
J Infect Dis 1998 Nov;178 Suppl 1:S91-4 

Watson CP 
An argument is presented here for postherpetic neuralgia as an intractable 
end-stage disorder for many patients. The exciting possibility of 
prevention of this disorder by early, aggressive treatment exists; however, 
the extent to which therapy can be effective is unknown. Early, aggressive 
treatment of the pain of herpes zoster is, nevertheless, urged, and the 
options for treatment are discussed. These options include antiviral 
therapy within the first 72 h, if possible, from the onset of rash or 
radicular pain and the use of analgesics, including opioids (if necessary), 
nerve blocks, and early antidepressant therapy. In addition, the extent to 
which vaccination of older adults will prevent postherpetic neuralgia is 
unknown but appears to hold promise. 

================================================================= 
17.) Postherpetic neuralgia: impact of famciclovir, age, rash severity, and 
acute pain in herpes zoster patients. 
================================================================= 
J Infect Dis 1998 Nov;178 Suppl 1:S76-80 

Dworkin RH, Boon RJ, Griffin DR, Phung D 
Department of Anesthesiology, University of Rochester School of Medicine 
and Dentistry, New York 14642, USA. [email protected] 

New and previously reported analyses of the data from a placebo-controlled 
trial of famciclovir are reviewed in light of recently proposed 
recommendations for the analysis of pain in herpes zoster trials. The 
analyses examined the effect of famciclovir treatment on the duration of 
postherpetic neuralgia (PHN), which was defined as pain persisting after 
rash healing, pain persisting > 30 days after study enrollment, or pain 
persisting > 3 months after study enrollment; the baseline characteristics 
of patients in the famciclovir and placebo groups who developed PHN; the 
impact of famciclovir treatment on the duration of PHN, while controlling 
for significant covariates; and the prevalence of PHN at monthly intervals 
from 30 to 180 days after enrollment. The results of these analyses 
indicated that greater age, rash severity, and acute pain severity are risk 
factors for prolonged PHN. In addition, they demonstrated that treatment of 
acute herpes zoster patients with famciclovir significantly reduces both 
the duration and prevalence of PHN. 

================================================================= 
18.) The identification of risk factors associated with persistent pain 
following herpes zoster. 
================================================================= 
J Infect Dis 1998 Nov;178 Suppl 1:S71-5 

Whitley RJ, Shukla S, Crooks RJ 
Department of Pediatrics, Microbiology, and Medicine, University of Alabama 
at Birmingham 35233, USA. [email protected] 

Demographic and clinical characteristics of patients with herpes zoster at 
the time of presentation predict the duration and severity of pain on 
long-term follow-up. Analyses by Cox's proportional hazard models of six 
databases from controlled trials of antiviral drugs (total subjects = 2367) 
identified covariates for zoster-associated pain; all tests for 
significance were two-sided. Age strongly influenced pain outcome: patients 
> or = 50 years old were significantly more likely to have prolonged 
zoster-associated pain compared with those < 30 years old. Patients with 
prodromal symptoms or moderate or severe pain at presentation were also 
more likely to experience prolonged zoster-associated pain. Neither time to 
initiating treatment after rash onset nor sex of patient influenced pain 
outcome. Advancing age, prodromal symptoms, and acute pain severity at 
presentation predicted those individuals most at risk of prolonged pain and 
postherpetic neuralgia. When two or more of these factors were present, the 
risk of persistent pain was increased. 

================================================================= 
19.) Gabapentin for the treatment of postherpetic neuralgia: a randomized 
controlled trial. 
================================================================= 
JAMA 1998 Dec 2;280(21):1837-42 

Rowbotham M, Harden N, Stacey B, Bernstein P, Magnus-Miller L 
UCSF Pain Clinical Research Center, University of California, San Francisco 
94115, USA. 

CONTEXT: Postherpetic neuralgia (PHN) is a syndrome of often intractable 
neuropathic pain following herpes zoster (shingles) that eludes effective 
treatment in many patients. OBJECTIVE: To determine the efficacy and safety 
of the anticonvulsant drug gabapentin in reducing PHN pain. DESIGN: 
Multicenter, randomized, double-blind, placebo-controlled, parallel design, 
8-week trial conducted from August 1996 through July 1997. SETTING: Sixteen 
US outpatient clinical centers. PARTICIPANTS: A total of 229 subjects were 
randomized. INTERVENTION: A 4-week titration period to a maximum dosage of 
3600 mg/d of gabapentin or matching placebo. Treatment was maintained for 
another 4 weeks at the maximum tolerated dose. Concomitant tricyclic 
antidepressants and/or narcotics were continued if therapy was stabilized 
prior to study entry and remained constant throughout the study. MAIN 
OUTCOME MEASURES: The primary efficacy measure was change in the average 
daily pain score based on an 11-point Likert scale (0, no pain; 10, worst 
possible pain) from baseline week to the final week of therapy. Secondary 
measures included average daily sleep scores, Short-Form McGill Pain 
Questionnaire (SF-MPQ), Subject Global Impression of Change and 
investigator-rated Clinical Global Impression of Change, Short Form-36 
(SF-36) Quality of Life Questionnaire, and Profile of Mood States (POMS). 
Safety measures included the frequency and severity of adverse events. 
RESULTS: One hundred thirteen patients received gabapentin, and 89 (78.8%) 
completed the study; 116 received placebo, and 95 (81.9%) completed the 
study. By intent-to-treat analysis, subjects receiving gabapentin had a 
statistically significant reduction in average daily pain score from 6.3 to 
4.2 points compared with a change from 6.5 to 6.0 points in subjects 
randomized to receive placebo (P<.001). Secondary measures of pain as well 
as changes in pain and sleep interference showed improvement with 
gabapentin (P<.001). Many measures within the SF-36 and POMS also 
significantly favored gabapentin (P< or =.01). Somnolence, dizziness, 
ataxia, peripheral edema, and infection were all more frequent in the 
gabapentin group, but withdrawals were comparable in the 2 groups (15 
[13.3%] in the gabapentin group vs 11 [9.5%] in the placebo group). 
CONCLUSIONS: Gabapentin is effective in the treatment of pain and sleep 
interference associated with PHN. Mood and quality of life also improve 
with gabapentin therapy. 

================================================================= 
20.) [Clinical course and treatment of herpetic trigeminal ganglionic 
neuropathy]. 
================================================================= 
Zh Nevrol Psikhiatr Im S S Korsakova 1998;98(11):4-8 


Grachev IuV, Kukushkin ML, Sudarikov AP, Zhuravlev VF, Gerasimenko MIu 
45 patients were observed in the periods of both acute herpes zoster and 
postherpetic neuralgia (PHN). In most of the patients herpetic eruptions 
were located in the areas of innervation of the first branch of the 
trigeminal nerve. In acute period of the disease there were used aciclovir, 
helepin or alpisarinum, antiherpetic immunoglobulin, deoxyribonuclease, 
non-narcotic analgetics were used. Of 28 patients residual PHN was observed 
in 6 cases, delayed PHN (during 3 months)--in 2 patients. The PHN 
development was characteristic for elderly patients, delayed request for 
medical care, concomitant diseases, eruptions with hemorrhagic component 
and secondary pyodermia and considerable residual sensory deficit. In 
therapy of PHN the most effective drugs were amitriptylin, non-narcotic 
analgetics, anticonvulsants as well as acupuncture and electroacupuncture. 
Relief of a typical deafferentation of pain syndrome was achieved by means 
of ultrasonic destruction of the trigeminal nucleus (one case). Early 
therapy of acute herpes zoster does not prevent completely PHN development, 
but it decreased considerably probability of its forming as well as the 
severity of its course. 

================================================================= 
21.) Unilateral postherpetic neuralgia is associated with bilateral sensory 
neuron damage. 
================================================================= 
Ann Neurol 1998 Nov;44(5):789-95 

Oaklander AL, Romans K, Horasek S, Stocks A, Hauer P, Meyer RA 
Department of Neurosurgery, the Johns Hopkins Medical Institutions, 
Baltimore, MD, USA. 

Shingles can cause chronic neuropathic pain (postherpetic neuralgia) long 
after skin lesions heal. To investigate its causes, we quantitated 
immunolabeled sensory neurites in skin biopsies from 18 subjects with and 
16 subjects without postherpetic neuralgia after unilateral shingles. 
Subjects rated the intensity of their pain. Punch skin biopsies were 
evaluated from the site of maximum pain or shingles involvement, the 
homologous contralateral location, and a site on the back, distant from 
shingles involvement. Sections were immunostained with anti-PGP9.5 
antibody, a pan-axonal marker, and the density of epidermal and dermal 
neurites determined. The group with postherpetic neuralgia had a mean 
density of 339 +/- 97 neurites/mm2 in shingles-affected epidermis compared 
with a density of 1,661 +/- 262 neurites/mm2 for subjects without pain. 
Neurite loss was more severe in epidermis than dermis. Unexpectedly, the 
group with pain had also lost half of the neurites in contralateral 
epidermis. Contralateral damage occurred despite the lack of contralateral 
shingles eruptions or pain, correlated with the presence and severity of 
ongoing pain at the shingles site, and did not extend to the distant site. 
Thus, the pathophysiology of postherpetic neuralgia pain may involve a new 
bilateral mechanism. 

================================================================= 
22.) CSF and MRI findings in patients with acute herpes zoster. 
================================================================= 
Neurology 1998 Nov;51(5):1405-11 

Haanpaa M, Dastidar P, Weinberg A, Levin M, Miettinen A, Lapinlampi A, 
Laippala P, Nurmikko T 
Department of Neurology, Tampere University Hospital, Finland. 

OBJECTIVE: To explore MRI and CSF findings in patients with herpes zoster 
(HZ) and to correlate the findings with clinical manifestations of the 
disease. METHODS: Fifty immunocompetent patients (mean age, 59 years; 
range, 17 to 84 years) with HZ of fewer than 18 days duration participated. 
None had clinical signs of meningeal irritation, encephalitis, or myelitis. 
In 42 patients (84%), the symptoms constituted pain and rash only. Six 
patients (12%) had motor paresis, and three patients (6%) had ocular 
complications. One to three CSF samples were obtained from 46 patients (the 
first sampling taken 1 to 18 days from onset of rash), and 16 patients (all 
with either trigeminal or cervical HZ) underwent MRI of the brain. The 
clinical follow-up continued at least 3 months. RESULTS: CSF was abnormal 
in 28/46 patients (61%): pleocytosis (range, 5 to 1,440 microL) was 
detected in 21, elevated protein concentration in 12, varicella zoster 
virus (VZV) DNA in 10, and immunoglobulin G antibody to VZV in 10. These 
changes were more common in patients with acute complications, although 
they did not predict development of postherpetic neuralgia (PHN). In 9/16 
patients (56%), MRI lesions attributable to HZ were seen in the brainstem 
and cervical cord. At 3 months, 5/9 patients (56%) with abnormal MRI had 
PHN, whereas none of the 7 patients with no HZ-related lesions on MRI had 
any remaining pain. CONCLUSIONS: Subclinical extension of viral 
inflammation into the CNS occurs commonly in HZ. This finding may have 
implications for treatment of HZ and prevention of various associated 
complications. 

================================================================= 
23.) In vitro activity of acetylsalicylic acid on replication of 
varicella-zoster virus. 
================================================================= 
New Microbiol 1998 Oct;21(4):397-401 

Primache V, Binda S, De Benedittis G, Barbi M 
Institute of Virology, University of Milan, Italy. 

Topical application of a mixture of acetylsalicylic acid (ASA) and diethyl 
ether is effective in the treatment of acute herpes zoster and postherpetic 
neuralgia. To study whether the other-than-analgesic effects of that 
treatment could be due to an antiviral activity of ASA the effects of the 
drug on the replication of varicella zoster virus (VZV) were assessed by 
the fluorescent focus assay on MRC5 and Vero cells. ASA caused a marked 
reduction in the spread of infection in MRC5 monolayers while in growing 
Vero cells the effective dose proved toxic. ASA concentrations (5-10 mM) 
which were effective in vitro against VZV are higher than the plasma 
concentrations attained in the standard treatment of chronic inflammatory 
states, but are consistent with the skin concentration attained by topical 
application of ASA/diethyl ether mixture. These data support similar 
findings relating the antiviral activity of acetylsalicylic acid to 
influenza virus, CMV, and HIV. 

================================================================= 
24.) Herpes zoster in children and adolescents. 
================================================================= 
Pediatr Infect Dis J 1998 Oct;17(10):905-8 

Petursson G, Helgason S, Gudmundsson S, Sigurdsson JA 
Department of Family Medicine, University of Iceland, Reykjavik. 

OBJECTIVES: To follow the clinical course of herpes zoster and to determine 
the incidence, frequency of complications and association with malignancy 
in children and adolescents. DESIGN: Prospective cohort study in a primary 
health care setting in Iceland. The main outcome measures were age and sex 
distribution of patients and discomfort or pain 1, 3 and 12 months after 
the rash and general health before and 3 to 6 years after the zoster 
episode. RESULTS: During observation of the target population for a period 
of 75750 person years, 121 episodes of acute zoster developed (incidence 
1.6/1000/year) in 118 patients. End points were gained for all 118 patients 
after 554 person years of follow-up. Systemic acyclovir was never used. No 
patient developed postherpetic neuralgia, moderate or severe pain or any 
pain lasting longer than 1 month from start of the rash (95% confidence 
interval, 0 to 0.03). Potential immunomodulating conditions were diagnosed 
in 3 patients (2.5%) within 3 months of contracting zoster. Only 5 (4%) had 
a history of severe diseases. CONCLUSIONS: The probability of postherpetic 
neuralgia in children and adolescents is extremely low. Zoster is seldom 
associated with undiagnosed malignancy in the primary care setting. 

================================================================= 
25.) Oral corticosteroids for pain associated with herpes zoster. 
================================================================= 
Ann Pharmacother 1998 Oct;32(10):1099-103 

Ernst ME, Santee JA, Klepser TB 
Division of Clinical and Administrative Pharmacy, College of Pharmacy, 
University of Iowa, Iowa City, IA 52242, USA. [email protected] 

It is apparent from published studies that corticosteroids do not prevent 
the development of postherpetic neuralgia. Earlier trials that indicated 
some benefit in both acute neuralgia and the prevention of postherpetic 
neuralgia are of limited use to clinicians due to problems with 
uncontrolled study designs, small sample sizes, and the absence of 
statistical analysis of the results. The lack of a consensus definition of 
postherpetic neuralgia, the variable agents and dosages used, and the 
different pain scales reported are of concern when trying to interpret the 
results of these studies for their clinical significance. In more recent 
larger and well-designed studies, similar rates of postherpetic neuralgia 
were observed in the corticosteroid and control groups. As a result of 
these findings, corticosteroids should not be recommended for the 
prevention of postherpetic neuralgia. Despite lack of efficacy in 
preventing postherpetic neuralgia, limited studies suggest corticosteroids 
such as prednisone (40-60 mg/d tapered over 3 wk) are well tolerated and 
may confer slightly significant benefits in reducing the duration of acute 
neuralgia and improving quality-of-life measures. However, the clinical 
significance and application of these findings remain to be addressed. If 
corticosteroids are used for acute neuralgia, clinicians are advised to 
select their patients carefully. The patients treated in these studies were 
generally healthy and free of comorbid diseases, such as hypertension, 
diabetes mellitus, and psychiatric disorders, which can be exacerbated in 
the presence of corticosteroids. Although dissemination of herpes zoster 
has been reported infrequently, it remains a potential risk with use of 
corticosteroids. Until the results of these studies are repeated in more 
diverse patient populations, corticosteroids appear to have a limited role 
in the management of acute neuralgia associated with herpes zoster. 

================================================================= 
26.) Toxic effects of capsaicin on keratinocytes and fibroblasts. 
================================================================= 
J Burn Care Rehabil 1998 Sep-Oct;19(5):409-13 

Ko F, Diaz M, Smith P, Emerson E, Kim YJ, Krizek TJ, Robson MC 
Bay Pines Veterans Administration Medical Center, Institute of Tissue 
Regeneration, Repair and Rehabilitation, FL 33744, USA. 

Pain management for partial-thickness burns and split-thickness skin graft 
donor sites remains a persistent problem. Topical capsaicin 
(trans-b-methyl-N-vanillyl-noneamide) has been successful for pain relief 
in postherpetic neuralgia, arthritis, and diabetic neuropathy. It is 
thought to work by inhibiting type C cutaneous factors and by releasing 
substance P, which is essential for wound healing. To evaluate the effects 
of topical capsaicin treatment on burn wounds and donor sites, an in vitro 
study was designed to consider cytotoxic effects of commercial 
concentrations of capsaicin on keratinocytes and fibroblasts. Human 
keratinocytes and human fibroblasts were grown in tissue culture and 
exposed to varying concentrations of capsaicin (0.025% weight/volume to 
0.2% weight/volume). In addition, fibroblast-seeded collagen matrixes were 
exposed to capsaicin to evaluate the compound's ability to cause cytotoxic 
effects beneath the surface. Keratinocyte growth was reduced 21% to 31% in 
commercial concentrations of capsaicin 0.025% to 0.20% weight/volume. 
Fibroblasts were reduced 5% to 10% during the first 6 hours of exposure to 
capsaicin and 30% after 24 hours across the full range of concentrations 
tested. At concentrations of at least 0.1% weight/volume, capsaicin 
penetrated the collagen matrixes, resulting in fibroblast degeneration not 
only on the surface but also in the inner layers. On the basis of the fact 
that capsaicin was demonstrated to be cytotoxic to keratinocytes and 
fibroblasts and on the basis of its known detrimental effect on wound 
healing, it does not appear that topical capsaicin is indicated for the 
treatment of burns. 

================================================================= 
27.) Gamma knife treatment of trigeminal neuralgia: clinical and 
electrophysiological study. 
================================================================= 
Stereotact Funct Neurosurg 1998 Oct;70 Suppl 1:200-9 

Urgosik D, Vymazal J, Vladyka V, Liscak R 
Department of Stereotactic and Radiation Neurosurgery, Hospital Na Homolce, 
Prague, Czech Republic. 

Between October 1995 and October 1996, we treated 49 patients suffering 
from trigeminal neuralgia with Gamma Knife radiosurgery. There were 23 
males and 26 females. The mean age was 68 (range 38-94 years) The root of 
the trigeminal nerve close to brain stem was chosen as the target. The 
maximum dose was 70 Gy in 24 cases and 80 Gy in 25 cases. A single shot 
with the 4-mm collimator was used. 13 patients underwent Gamma Knife 
treatment of trigeminal nerve root without any previous surgical 
procedures. 31 patients suffered from an essential neuralgia (EN), while 7 
had neuralgia related to multiple sclerosis (MS). Three had atypical 
neuralgia (AN) and 8 patients had postherpetic neuralgia (PN). Patients 
were divided into five groups according to pain reduction. The success rate 
of pain relief (excellent, very good and good responses) in these patients 
was: EN 77% of patients, MS 43%, AN 33% and PN 38% of patients. Pain relief 
occurred after latent intervals of between 1 day and 8 months (median 2 
months and mean 2.8 months). Clinically detected complications after 
radiosurgery occurred only in the form of tactile hypesthesia in 6%. In a 
selected group of 18 patients, we observed slight electrophysiological 
changes in 2 patients (11%) after Gamma Knife treatment. 

================================================================= 
28.) Nortriptyline versus amitriptyline in postherpetic neuralgia: a 
randomized trial. 
================================================================= 
Neurology 1998 Oct;51(4):1166-71 

Watson CP, Vernich L, Chipman M, Reed K 
Etobicoke General Hospital, Canada. 

OBJECTIVE (BACKGROUND): Amitriptyline (AT) is a standard therapy for 
postherpetic neuralgia (PHN). Our hypothesis was that nortriptyline (NT), a 
noradrenergic metabolite of AT, may be more effective. METHODS: A 
randomized, double-blind, crossover trial of AT versus NT was conducted in 
33 patients. RESULTS: Thirty-one patients completed the trial. Twenty-one 
of 31 (67.7%) had at least a good response to AT or NT, or both. We found 
no difference with regard to relief of steady, brief, or skin pain by 
visual analog scales for pain and pain relief; mood; disability; 
satisfaction; or preference between the two drugs. Intolerable side effects 
were more common with AT. Most patients (26/33) were not depressed, and 
most responding showed no change in rating scales for depression despite 
the occurrence of pain relief. CONCLUSIONS: We concluded that this study 
provides a scientific basis for an analgesic action of NT in PHN because 
pain relief occurred without an antidepressant effect, and that although 
there were fewer side effects with NT, AT and NT appear to have a similar 
analgesic action for most individuals. 

================================================================= 
29.) [Lidocaine tape (Penles--a dressing tape based on 60% lidocaine-) 
reduces the pain of postherpetic neuralgia]. 
================================================================= 
Masui 1998 Jul;47(7):882-4 

Tamakawa S, Ogawa H 
Department of Anesthesia, Rumoi Municipal Hospital. 

The treatment of postherpetic neuralgia (PHN) by topical administration of 
local anesthetics has a number of drawbacks. Lidocaine tape (Penles) is a 
15 cm2 dressing tape based on 60% lidocaine used to anesthetize skin when 
an intravenous catheter is inserted. This study aims to evaluate the 
analgesic efficacy of lidocaine tape in patients with PHN by comparing the 
results with those of surgical drape (Tegaderm). In a single-blind, two 
session study, lidocaine tape or surgical drape was applied to the affected 
skin of 10 patients. In one session, lidocaine tape was applied to the 
painful skin area, and in another, surgical drape was applied to the same 
area. Pain score and side effects were measured over 12 hours. Pain score 
was reduced at measurements taken starting from 1 hour after lidocaine tape 
application (P < 0.05). Lidocaine tape induced minor side-effects, erythema 
in a patient and increase in pain in another patient. In conclusion, 
lidocaine tape is effective for relief of PHN. 

================================================================= 
30.) Postherpetic neuralgia: irritable nociceptors and deafferentation. 
================================================================= 
Neurobiol Dis 1998 Oct;5(4):209-27 

Fields HL, Rowbotham M, Baron R 
Department of Neurology, University of California at San Francisco 94143, 
USA. 

Postherpetic neuralgia (PHN) is a common and often devastatingly painful 
condition. It is also one of the most extensively investigated of the 
neuropathic pains. Patients with PHN have been studied using quantitative 
testing of primary afferent function, skin biopsies, and controlled 
treatment trials. Together with insights drawn from an extensive and 
growing literature on experimental models of neuropathic pain these patient 
studies have provided a preliminary glimpse of the pain-generating 
mechanisms in PHN. It is clear that both peripheral and central 
pathophysiological mechanisms contribute to PHN pain. Some PHN patients 
have abnormal sensitization of unmyelinated cutaneous nociceptors 
(irritable nociceptors). Such patients characteristically have minimal 
sensory loss. Other patients have pain associated with small fiber 
deafferentation. In such patients pain and temperature sensation are 
profoundly impaired but light moving mechanical stimuli can often produce 
severe pain (allodynia). In these patients, allodynia may be due to the 
formation of new connections between nonnociceptive large diameter primary 
afferents and central pain transmission neurons. Other deafferentation 
patients have severe spontaneous pain without hyperalgesia or allodynia and 
presumably have lost both large and small diameter fibers. In this group 
the pain is likely due to increased spontaneous activity in deafferented 
central neurons and/or reorganization of central connections. These three 
types of mechanism may coexist in individual patients and each offers the 
possibility for developing new therapeutic interventions. 

================================================================= 
31.) The caudalis DREZ for facial pain. 
================================================================= 
Stereotact Funct Neurosurg 1997;68(1-4 Pt 1):168-74 

Bullard DE, Nashold BS Jr 
Raleigh Neurosurgical Clinic, N.C., USA. 

During a 3-year period, 25 caudalis dorsal root entry zone (DREZ) 
operations were done for severe, facial pain. Intraoperative brainstem 
recordings were done before and after DREZ in all patients. Primary 
diagnosis included refractory trigeminal neuralgia, atypical headaches or 
facial pain, posttraumatic closed head injuries, postsurgical anesthesia 
dolorosa, multiple sclerosis, brainstem infarction, postherpetic neuralgia 
and cancer-related pain. At the time of discharge, good to excellent pain 
relief was present in 24/25 patients and fair relief in 1. At 1 month, 
19/25 (76%) patients had good to excellent results and at 3 months 
following surgery, 17/25 (68%) continued to have good to excellent pain 
relief. One year following surgery, 18 patients could be evaluated, 12/18 
(67%) still considered their relief as good to excellent, 2 fair and 4 
poor. Transient postoperative ataxia was present in 15/25 patients (60%), 
but was largely resolved at 1 months. In 3/18 (17%) patients, a degree of 
ataxia was still present at 1 year although in none was it disabling. Two 
patients had transient diplopia, and 3 had increased corneal anesthesia 
with 1 later developing a keratitis. No surgical or postsurgical mortality 
was noted. This procedure has proven to be a satisfactory treatment for 
many patients with debilitating facial pain syndromes with acceptable 
morbidity. 

================================================================= 
32.) DREZ coagulations for deafferentation pain related to spinal and 
peripheral nerve lesions: indication and results of 79 consecutive procedures. 
================================================================= 
Stereotact Funct Neurosurg 1997;68(1-4 Pt 1):161-7 

Rath SA, Seitz K, Soliman N, Kahamba JF, Antoniadis G, Richter HP 
Department of Neurosurgery, University of Ulm, Gunzburg, Germany. 

During a 16 years' period, a total of 79 dorsal root entry zone 
coagulations were performed in 68 patients for deafferentation pain. Of the 
23 patients who underwent surgery for pain due to cervical root avulsion, 
18 (82%) had a good (12) or fair (6) pain relief (mean follow-up period 51 
months). Twelve (57%) patients with spinal cord injuries noted continuous 
pain reduction (10 good, 2 fair; mean follow-up 52 months). Continuous 
marked improvement for longer periods was reported only by 2 out of 10 
patients with postherpetic neuralgia and 1 out of 7 patients with painful 
states due to other brachial plexus lesions and none out of 5 with spinal 
cord lesions (3) and phantom limb pain (2). 

================================================================= 
33.) Jaipur block in postherpetic neuralgia. 
================================================================= 
Int J Dermatol 1998 Jun;37(6):465-8 

Bhargava R, Bhargava S, Haldia KN, Bhargava P 
Department of Dermatology, SMS Medical College, Jaipur, India. 

BACKGROUND: Postherpetic neuralgia, a common sequele to herpes zoster 
infection, is a chronic debilitating problem. The available therapeutic 
modalities are usually ineffective. METHODS: A total of 3960 patients (1326 
women and 2634 men; age group, 21-84 years), with postherpetic neuralgia as 
the presenting complaint and with pain lasting from 2 months to 5 years, 
were treated with Jaipur block, consisting of local subcutaneous 
infiltration of 2% xylocaine, 0.5% bupivacaine, and 4 mg/mL dexamethasone 
solution. Patients were followed up at six-weekly intervals with subsequent 
injections given in non-responders. RESULTS: Twenty-eight per cent of 
patients obtained complete relief from pain after a single injection, 
another 57% after a second injection, and 11% after a third injection; 4% 
of patients did not respond to treatment. The non-responders were either 
old (over 60 years) or had pain lasting for more than 2 years. The response 
to therapy was similar in both sexes. There were 31 left-handed patients in 
this study. Pain was less severe in left-handed patients and they obtained 
complete relief after a single injection. Side-effects including giddiness 
and sweating were seen, occasionally, in a few patients. CONCLUSIONS: 
Ninety six per cent of patients obtained complete relief after the block 
with a follow-up of up to 19 years. 

================================================================= 
34.) Efficacy of oxycodone in neuropathic pain: a randomized trial in 
postherpetic neuralgia. 
================================================================= 
Neurology 1998 Jun;50(6):1837-41 

Watson CP, Babul N 
Department of Medicine, University of Toronto, Ontario, Canada. 

OBJECTIVE: Although opioid analgesics are used in the management of 
neuropathic pain syndromes, evidence of their efficacy remains to be 
established. We evaluated the clinical efficacy and safety of oxycodone in 
neuropathic pain using postherpetic neuralgia as a model. METHODS: Patients 
with postherpetic neuralgia of at least moderate intensity were randomized 
to controlled-release oxycodone 10 mg or placebo every 12 hours, each for 4 
weeks, using a double-blind, crossover design. The dose was increased 
weekly up to a possible maximum of 30 mg every 12 hours. Pain intensity and 
pain relief were assessed daily, and steady (ongoing) pain, brief 
(paroxysmal) pain, skin pain (allodynia), and pain relief were recorded at 
weekly visits. Clinical effectiveness, disability, and treatment preference 
were also assessed. RESULTS: Fifty patients were enrolled and 38 completed 
the study (16 men, 22 women, age 70+/-11 years, onset of postherpetic 
neuralgia 31+/-29 months, duration of pain 18+/-5 hours per day). The 
oxycodone dose during the final week was 45+/-17 mg per day. Compared with 
placebo, oxycodone resulted in pain relief (2.9+/-1.2 versus 1.8+/-1.1, 
p=0.0001) and reductions in steady pain (34+/-26 versus 55+/-27 mm, 
p=0.0001), allodynia (32+/-26 versus 50+/-30 mm, p=0.0004), and paroxysmal 
spontaneous pain (22+/-24 versus 42+/-32 mm, p=0.0001). Global 
effectiveness, disability, and masked patient preference all showed 
superior scores with oxycodone relative to placebo (1.8+/-1.1 versus 
0.7+/-1.0, p=0.0001; 0.3+/-0.8 versus 0.7+/-1.0, p=0.041; 67% versus 11%, 
p=0.001, respectively). CONCLUSIONS: Controlled-release oxycodone is an 
effective analgesic for the management of steady pain, paroxysmal 
spontaneous pain, and allodynia, which frequently characterize postherpetic 
neuralgia. 

================================================================= 
35.) Intracutaneous histamine injection can detect damage of cutaneous 
afferent fibres in postherpetic neuralgia. 
================================================================= 
Dermatology 1997;195(4):311-6 

Stucker M, Hugler P, von Kobyletzki G, Reuther T, Hoffmann K, Laubenthal H, 
Altmeyer P 
Department of Dermatology, Ruhr University, Bochum, Germany. 

BACKGROUND: The axon reflex response in diseased skin of patients with 
postherpetic neuralgia may be significantly impaired. OBJECTIVE: In the 
present study we introduced a simple test for quantifying the decreased 
axon reflex flare response in the clinical routine. METHODS: Histamine was 
intradermally applied to the diseased dermatome as well as to the 
corresponding dermatome of the contralateral side of the body. Ten minutes 
after application, skin blood flow and the extension of the hyperaemic 
response were assessed by means of laser Doppler scanning. RESULTS: In the 
skin region affected by the postherpetic neuralgia, the hyperaemic area was 
significantly smaller than in the healthy skin. The mean flux values did 
not differ significantly between the two sites. There was no correlation 
between the hyperaemic response and the intensity of pain sensation 
assessed by a clinical visual analogue score. CONCLUSION: The smaller 
hyperaemic area in the dermatome with postherpetic neuralgia strongly 
indicates a C fibre or C nociceptor damage. We consider histamine 
injections as a useful tool in the differential diagnosis of postherpetic 
neuralgia. 

================================================================= 
36.) The management of postherpetic neuralgia. 
================================================================= 
Postgrad Med J 1997 Oct;73(864):623-9 

Bowsher D 
Pain Research Institute, Walton Hospital, Liverpool, UK. 

Postherpetic neuralgia is defined as pain persisting, or recurring, at the 
site of shingles at least three months after the onset of the acute rash. 
Thus defined, at least half of shingles sufferers over the age of 65 years 
develop postherpetic neuralgia. In addition to increasing age, less 
important risk factors for postherpetic neuralgia are pain severity of 
acute shingles and trigeminal distribution. Postherpetic neuralgia accounts 
for 11-15% of all referrals to pain clinics and would, in fact, be far more 
effectively dealt with in primary care. Effective treatment of acute 
shingles by systemic antivirals at the appropriate time may have some 
effect in reducing the incidence of postherpetic neuralgia, making it 
easier to treat with tricyclics and greatly reducing scarring (25% of all 
cases affect the face). Pre-emptive treatment with low-dose tricyclics 
(ami- or nor-triptyline 10-25 mg nocte) from the time of diagnosis of acute 
shingles reduces the incidence of postherpetic neuralgia by about 50%. 
Established postherpetic neuralgia should be vigorously treated with 
adrenergically active tricyclics in a dose rising over two or three weeks 
from 10-25 mg to 50-75 mg. Positive relaxation should also be used. 
Carbamazepine, like conventional analgesics, is of little or no value. 
Failure of tricyclics to effect relief within eight weeks calls for 
specialist treatment. North American practitioners in particular believe 
that some opioids (e.g., oxycodone) may be helpful in otherwise intractable 
cases. 

================================================================= 
37.) The "three-in-one block" for treatment of pain in a patient with acute 
herpes zoster infection. 
================================================================= 
Reg Anesth 1997 Nov-Dec;22(6):575-8 

Hadzic A, Vloka JD, Saff GN, Hertz R, Thys DM 
Department of Anesthesiology, St. Luke's-Roosevelt Hospital Center, 
Columbia University College of Physicians and Surgeons, New York, New York 
10025, USA. 

BACKGROUND AND OBJECTIVES: Herpes zoster infection in elderly patients 
frequently results in disabling pain, carries a high risk of postherpetic 
neuralgia (PHN), and can pose a significant therapeutic challenge. METHODS: 
We describe a successful use of the perivascular technique of lumbar plexus 
blockade ("three-in-one block") for treatment of pain during acute herpes 
zoster infection in an 82-year-old severely ill patient in whom other 
modalities were contraindicated. RESULTS: Three-in-one block using 40 mL of 
0.25% bupivacaine with 1:300,000 epinephrine resulted in excellent pain 
relief that lasted for 2 weeks. CONCLUSIONS: The perivascular technique of 
lumbar plexus blockade may be a useful alternative to epidural and 
paravertebral techniques of lumbar blockade in the occasional patient for 
whom these other approaches are contraindicated. 

================================================================= 
38.) Use of gabapentin in pain management. 
================================================================= 
Ann Pharmacother 1997 Sep;31(9):1082-3 

Wetzel CH, Connelly JF 
School of Pharmacy, Campbell University, Buies Creek, NC, USA. 

There have been many proposed uses for gabapentin, including midscapular 
pain secondary to radiation myelopathy, RSD, neuropathic pain, postherpetic 
neuralgia, and migraine prophylaxis. However, the published reports consist 
of a small number of patients and limited data. Limited data provided in 
published case reports do not allow adequate evaluation of expected adverse 
effects or efficacy. It is unclear whether gabapentin is more effective for 
a specific type of pain and how gabapentin may compare with placebo or 
other therapeutic alternatives. Therefore, randomized, double-blind, 
placebo-controlled, prospective studies are warranted to further elucidate 
gabapentin uses beyond what is recommended by the Food and Drug 
Administration. Gabapentin should only be considered for pain management 
after well-established therapies have failed to produce desired outcomes. 

================================================================= 
39.)Peppers and pain. The promise of capsaicin. 
================================================================= 
Drugs 1997 Jun;53(6):909-14 

Fusco BM, Giacovazzo M 
Department of Clinical Medicine, University La Sapienza, Rome, 1taly. 
[email protected] 

Capsaicin, the most pungent ingredient in red peppers, has been used for 
centuries to remedy pain. Recently, its role has come under reinvestigation 
due to evidence that the drug acts selectively on a subpopulation of 
primary sensory neurons with a nociceptive function. These neurons, besides 
generating pain sensations, participate through an antidromic activation in 
the process known as neurogenic inflammation. The first exposure to 
capsaicin intensely activates these neurons in both senses (orthodromic: 
pain sensation; antidromic: local reddening, oedema etc.). After the first 
exposure, the neurons become insensitive to all further stimulation 
(including capsaicin itself). This evidence led to the proposal of 
capsaicin as a prototype of an agent producing selective analgesia. This 
perspective is radically different from previous 'folk medicine' cures, 
where the drug was used as a counter-irritating agent (i.e. for muscular 
pain). The new concept requires that capsaicin be repeatedly applied on the 
painful area to obtain the desensitisation of the sensory neurons. 
Following this idea, capsaicin has been used successfully in controlling 
pain in postherpetic neuralgia, diabetic neuropathy and other conditions of 
neuropathic pain. Furthermore, evidence indicates that capsaicin could also 
control the pain of osteoarthritis. Finally, repeated applications of the 
drug to the nasal mucosa result in the prevention of cluster headache 
attacks. On the basis of this evidence, capsaicin appears to be a promising 
prototype for obtaining selective analgesia in localised pain syndromes. 

================================================================= 
40.) Economic evaluation of famciclovir in reducing the duration of 
postherpetic neuralgia. 
================================================================= 
Am J Health Syst Pharm 1997 May 15;54(10):1180-4 

Huse DM, Schainbaum S, Kirsch AJ, Tyring S 
Medical Research International, Burlington, MA 01803, USA. 

The economic impact of famciclovir therapy for postherpetic neuralgia (PHN) 
in patients with acute herpes zoster was studied. A decision-analytic model 
of the treatment of herpes zoster and PHN was used to compare the cost of 
PHN between patients treated with oral famciclovir 500 mg three times daily 
for seven days and patients not receiving any antiviral therapy. The 
effects of famciclovir on PHN in the model were based on the results of a 
randomized, double-blind trial in 419 adult outpatients. The cost of the 
course of famciclovir therapy (21 tablets) was estimated as the sum of the 
drug's wholesale acquisition cost and the pharmacy dispensing cost. The 
cost of treating PHN (physician visits, medications, and miscellaneous 
nondrug therapy) was estimated by consulting a panel of physicians. 
According to the model, the cost of treating PHN was $85 lower per 
famciclovir recipient ($294 for famciclovir versus $379 for no antiviral 
therapy). The net cost of famciclovir therapy was $23 per patient ($108 for 
acquisition and dispensing minus the $85 savings). Among patients 50 years 
of age or older, famciclovir reduced the average cost of PHN by $155 ($414 
for famciclovir versus $569 for no antiviral therapy) and yielded a net 
savings of $7 per patient. A model for the use of famciclovir to treat 
acute herpes zoster showed that the cost of such therapy was largely offset 
by savings in the cost of treating this complication. 

================================================================= 
41.) The effects of pre-emptive treatment of postherpetic neuralgia with 
amitriptyline: a randomized, double-blind, placebo-controlled trial. 
================================================================= 
Bowsher D 
Pain Research Institute, Walton Hospital, Liverpool, United Kingdom. 
J Pain Symptom Manage (UNITED STATES) Jun 1997 13 (6) p327-31 ISSN: 
0885-3924 
Language: ENGLISH 
Document Type: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED 
TRIAL 
Journal Announcement: 9710 
Subfile: NURSING 
Seventy-two patients older than 60 years of age who received a diagnosis 
of herpes 
zoster (HZ) were entered into a randomized, double-blind, 
placebo-controlled trial of 
daily amitriptyline 25 mg. Treatment with either amitriptyline or placebo 
continued 
for 90 days after diagnosis. Pain prevalence at 6 months was the primary 
outcome. 
Results showed that early treatment with low-dose amitriptyline reduced pain 
prevalence by more than one-half (p < 0.05; odds ratio, 2.9:1) This finding 
makes a 
strong case for the pre-emptive administration of amitriptyline, in 
combination with 
an antiviral drug, to elderly patients with acute herpes zoster. 

================================================================= 
42.) Persistence of varicella-zoster virus DNA in elderly patients with 
postherpetic 
neuralgia. 
================================================================= 
Mahalingam R; Wellish M; Brucklier J; Gilden DH 
Department of Neurology, University of Golorado Health Sciences Center, 
Denver 
80262, USA. 
J Neurovirol (ENGLAND) Mar 1995 1 (1) p130-3 ISSN: 1355-0284 
Contract/Grant No.: AG 06127--AG--NIA; NS 32623--NS--NINDS 
Language: ENGLISH 
Document Type: JOURNAL ARTICLE 
Journal Announcement: 9710 
Subfile: INDEX MEDICUS 
The most common complication of zoster in the elderly is postherpetic 
neuralgia, 
operationally defined as pain persisting longer than 1-2 months after rash. 
The 
cause of postherpetic neuralgia is unknown. Using polymerase chain 
reaction, we 
detected varicella zoster virus DNA in blood mononuclear cells from 11 of 51 
postherpetic neuralgia patients, but not in any of 19 zoster patients without 
postherpetic neuralgia, or in any of 11 elderly individuals without a 
history of 
zoster. Blood mononuclear cells from nine of 27 serially-bled postherpetic 
neuralgia 
patients were positive for varicella zoster virus DNA; six were positive 
once, and 
three patients were positive more than once. Our results indicated that 
postherpetic neuralgia may be related to persistence of varicella zoster 
virus. 

================================================================= 
43.) Risk factors for postherpetic neuralgia [see comments] 
================================================================= 
Choo PW; Galil K; Donahue JG; Walker AM; Spiegelman D; Platt R 
Channing Laboratory, Department of Medicine, Brigham and Women's 
Hospital, Boston, 
Mass, USA. 
Arch Intern Med (UNITED STATES) Jun 9 1997 157 (11) p1217-24 ISSN: 
0003-9926 
Note: Comment in: Arch Intern Med 1997 Jun 9;157(11):1166-7 
Language: ENGLISH 
Document Type: JOURNAL ARTICLE 
Journal Announcement: 9709 
Subfile: AIM; INDEX MEDICUS 
BACKGROUND: The risk factors for postherpetic neuralgia (PHN), the most 
common 
complication of herpes zoster, have not been well established. OBJECTIVE: To 
elucidate the risk factors for PHN. METHODS: Automated medical, claims, 
and pharmacy 
records of a health maintenance organization were used to identify cases of 
PHN and 
obtain data on risk factors. A case-base design was used to assess the 
impact of 
various patient, disease, and treatment factors on the prevalence of PHN 1 
and 2 
months after developing zoster. RESULTS: There were 821 cases of herpes 
zoster that 
met all eligibility criteria. The prevalence of PHN more than 30 days 
after onset of 
zoster was 8.0% (95% confidence interval [CI], 6.3%-10.1%) and 4.5% (95% 
CI, 3.2%- 
6.2%) after 60 days. Compared with patients younger than 50 years, 
individuals aged 
50 years or older had a 14.7-fold higher prevalence (95% CI, 6.8-32.0) 30 
days and a 
27.4-fold higher prevalence (95% CI, 8.8-85.4) 60 days after developing 
zoster. 
Prodromal sensory symptoms and certain conditions associated with compromised 
immunity were also associated with PHN. Systemic corticosteroids before 
zoster and 
treatment of zoster with acyclovir or corticosteroids did not significantly 
affect 
the prevalence of PHN. CONCLUSIONS: Increased age and prodromal symptoms are 
associated with higher prevalence of PHN 1 and 2 months after onset of 
zoster. 
Overall, systemic acyclovir appears not to confer any protection against PHN, 
although benefit among elderly patients cannot be excluded. 

================================================================= 
44.) Deep brain stimulation for intractable pain: a 15-year experience. 
================================================================= 
Kumar K; Toth C; Nath RK 
Department of Surgery, University of Saskatchewan, Regina, Canada. 
Neurosurgery (UNITED STATES) Apr 1997 40 (4) p736-46; discussion 746-7 
ISSN: 
0148-396X 
Language: ENGLISH 
Document Type: JOURNAL ARTICLE; REVIEW; REVIEW, MULTICASE 
Journal Announcement: 9709 
Subfile: INDEX MEDICUS 
OBJECTIVE: During the past 15 years, we prospectively followed 68 
patients with 
chronic pain syndromes who underwent deep brain stimulation (DBS). The 
objective of 
our study was to analyze the long-term outcomes to clarify patient 
selection criteria 
for DBS. METHODS: Patients were referred from a multidisciplinary pain 
clinic after 
conservative treatment failed. Electrodes for DBS were implanted within the 
periventricular gray matter, specific sensory thalamic nuclei, or the 
internal 
capsule. Each patient was followed on a 6-monthly follow-up basis and 
evaluated with 
a modified visual analog scale. RESULTS: Follow-up periods ranged from 6 
months to 
15 years, with an average follow-up period of 78 months. The mean age of 
the 54 men 
and 14 women in the study was 51.3 years. Indications for DBS included 43 
patients 
with failed back syndrome, 6 with peripheral neuropathy or radiculopathy, 5 
with 
thalamic pain, 4 with trigeminal neuropathy, 3 with traumatic spinal cord 
lesions, 2 
with causalgic pain, 1 with phantom limb pain, and 1 with carcinoma pain. 
After 
initial screening, 53 of 68 patients (77%) elected internalization of their 
devices; 
42 of the 53 (79%) continue to receive adequate relief of pain. Therefore, 
effective 
pain control was achieved in 42 of 68 of our initially referred patients 
(62%). 
Patients with failed back syndrome, trigeminal neuropathy, and peripheral 
neuropathy 
fared well with DBS, whereas those with thalamic pain, spinal cord injury, 
and 
postherpetic neuralgia did poorly. CONCLUSION: DBS in selected patients 
provides 
long-term effective pain control with few side effects or complications. (64 
References) 

================================================================= 
45.) [Treatment of post-herpes zoster pain with tramadol. Results of an 
open pilot study 
versus clomipramine with or without levomepromazine] 
================================================================= 
Traitement des douleurs post-zosteriennes par le tramadol. Resultats 
d'une etude 
pilote ouverte versus clomipramine avec ou sans levomepromazine. 
Gobel H; Stadler T 
Service de Neurologie, Hopital Universitaire, Kiel, Allemagne. 
Drugs (NEW ZEALAND) 1997 53 Suppl 2 p34-9 ISSN: 0012-6667 
Language: FRENCH Summary Language: ENGLISH 
Document Type: 
CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL 
English 
Abstract 
Journal Announcement: 9708 
Subfile: INDEX MEDICUS 
To date, no universally applicable recommendations are available for the 
treatment 
of patients with postherpetic neuralgia. A mixture of clinical anecdotes, 
experimental findings and observations from clinical trials form the basis 
of the 
medical arsenal for this condition. Tricyclic antidepressants are commonly 
used, and 
clinical experience and several investigations have documented their 
effectiveness. 
Today, single entity antidepressants, which can be combined with 
neuroleptics to 
increase analgesia, are generally recommended for the treatment of 
postherpetic 
neuralgia. Some authors also recommend the additional administration of an 
opioid if 
analgesia is inadequate. Just over a decade ago, opioids were considered 
ineffective 
for the treatment of neuropathic pain; however, more recent investigations 
relating 
to the use of opioids, primarily in the treatment of nontumour-related 
chronic pain, 
have led to a revision of their use in neuropathic pain. Nevertheless, the 
use of 
opioid therapy for neurogenic pain remains controversial. Tramadol is a 
synthetic, 
centrally acting analgesic with both opioid and nonopioid analgesic 
activity. The 
nonopioid component is related to the inhibition of noradrenaline 
(norepinephrine) 
reuptake and stimulation of serotonin (5-hydroxytryptamine; 5-HT) release 
at the 
spinal level. In this regard, there are parallels with antidepressants, 
which are 
believed to potentiate the effect of biogenic amines in endogenous 
pain-relieving 
systems. There is evidence that, in tramadol, both mechanisms act 
synergistically 
with respect to analgesia. The aim of this pilot study was to investigate, 
for the 
first time, the analgesic efficacy and tolerability of tramadol, compared 
with the 
antidepressant clomipramine, in the treatment of postherpetic neuralgia. If 
necessary, clomipramine was used in combination with the neuroleptic 
levomepromazine. 
The study allowed individualised dosages at predetermined intervals up to a 
maximum 
daily dose of tramadol 600mg and clomipramine 100mg, or clomipramine 100mg 
with or 
without levomepromazine 100mg. 21 (60%) of 35 randomised patients (> or = 
65 years) 
received the study medication over the 6-week period [tramadol n = 10; 
clomipramine 
with or without levomepromazine) n = 11]. After 3 weeks' treatment the 
dosage in 
both groups remained almost constant for the rest of the 6-week treatment 
phase (mean 
daily dose: tramadol 250 to 290mg; clomipramine 59.1 to 63.6mg). Only 3 
patients 
required the combination of clomipramine and levomepromazine. At the 
outset, both 
groups recorded an average pain level of 'moderate' to 'very severe'. In 
correlation 
with increasing the study medication, this had decreased to 'slight' by the 
end of 
the treatment, when 9 of 10 patients in the tramadol group and of 6 of 11 
patients in 
the clomipramine group retrospectively rated their analgesia as excellent, 
good or 
satisfactory. The psychological/physical condition of the patients did not 
change 
significantly during tramadol treatment. Sensitivity and depression 
parameters 
decreased in the clomipramine group. The incidence of adverse events for all 
patients was similar in both groups (tramadol 76.5%; clomipramine with or 
without 
levomepromazine 83.3%). In conclusion, tramadol would appear to be an 
interesting 
therapeutic alternative for pain relief in postherpetic neuralgia, 
particularly in 
patients who are not depressed. In clinical practice, tramadol and 
clomipramine can 
best be used differentially. For example, tramadol could be the drug of 
first choice 
in patients with obvious cardiovascular disease (not an uncommon problem in 
the > or 
= 65 year age group) in whom antidepressants are contraindicated, and 
similarly in 
patients in whom an antidepressant effect is not required. On the other 
hand, 
patients presenting with both postherpetic neuralgia and clinical 
depression but no 
obvious cardiovascular disease may benefit from the addition of an 
antidepressant. 
In order to achieve clinical success, 

================================================================= 
46.) High-dose oral dextromethorphan versus placebo in painful diabetic 
neuropathy and postherpetic neuralgia. 
================================================================= 
Nelson KA; Park KM; Robinovitz E; Tsigos C; Max MB 
Pain and Neurosensory Mechanisms Branch, National Institute of Dental 
Research, 
National Institutes of Health, Bethesda, MD 20892-1258, USA. 
Neurology (UNITED STATES) May 1997 48 (5) p1212-8 ISSN: 0028-3878 
Language: ENGLISH 
Document Type: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED 
TRIAL 
Journal Announcement: 9708 
Subfile: AIM; INDEX MEDICUS 
N-methyl-D-aspartate (NMDA) receptor antagonists relieve neuropathic pain 
in animal 
models, but side effects of dissociative anesthetic channel blockers, such as 
ketamine, have discouraged clinical application. Based on the hypothesis 
that low- 
affinity NMDA channel blockers might have a better therapeutic ratio, we 
carried out 
two randomized, double-blind, crossover trials comparing six weeks of oral 
dextromethorphan to placebo in two groups, made up of 14 patients with 
painful distal 
symmetrical diabetic neuropathy and 18 with postherpetic neuralgia. Thirteen 
patients with each diagnosis completed the comparison. Dosage was titrated 
in each 
patient to the highest level reached without disrupting normal activities; 
mean doses 
were 381 mg/day in diabetics and 439 mg/day in postherpetic neuralgia 
patients. In 
diabetic neuropathy, dextromethorphan decreased pain by a mean of 24% (95% 
CI: 6% to 
42%, p = 0.01), relative to placebo. In postherpetic neuralgia, 
dextromethorphan did 
not reduce pain (95% CI: 10% decrease in pain to 14% increase in pain, p = 
0.72). 
Five of 31 patients who took dextromethorphan dropped out due to sedation 
or ataxia 
during dose escalation, but the remaining patients all reached a reasonably 
well- 
tolerated maintenance dose. We conclude that dextromethorphan or other 
low-affinity 
NMDA channel blockers may have promise in the treatment of painful diabetic 
neuropathy. 

================================================================= 
47.) Herpes zoster and postherpetic neuralgia. Optimal treatment. 
================================================================= 
Johnson RW 
Pain Management Clinic, Bristol Royal Infirmary, University of Bristol, 
England. 
Drugs Aging (NEW ZEALAND) Feb 1997 10 (2) p80-94 ISSN: 1170-229X 
Language: ENGLISH 
Document Type: JOURNAL ARTICLE; REVIEW; REVIEW, TUTORIAL 
Journal Announcement: 9707 
Subfile: INDEX MEDICUS 
Herpes zoster is a common disease primarily affecting the elderly. 
Although some 
individuals experience no symptoms beyond the duration of the acute 
infection, many 
develop chronic pain [postherpetic neuralgia (PHN)], which is the commonest 
complication of herpes zoster infection and remains notoriously difficult 
to treat 
once established. It may persist until death and has major implications 
for quality 
of life and use of healthcare resources. Predictors for the development of 
PHN are 
present during the acute disease and should indicate the need for the use of 
preventive therapy. At the present time, use of antiviral and certain 
tricyclic 
antidepressant drugs, combined with psychosocial support, seem most 
effective, but 
are far from perfect. Sympathetic nerve blocks reduce acute herpetic pain 
but it is 
uncertain whether they prevent PHN. In the future, vaccines may have an 
important 
place in reducing the incidence of chickenpox in the population or, through 
the 
vaccination of middle-aged individuals, in boosting immunity to varicella 
zoster 
virus, thus preventing or modifying the replication of the virus from its 
latent 
phase that results in herpes zoster. Developments in the understanding of 
the 
pathophysiology of PHN indicate possible directions for improved drug 
management of 
established PHN, although no evidence yet exists for efficacy of the drugs 
concerned. 
Such agents include new generation anticonvulsants and N-methyl-D-aspartate 
antagonists. (111 References) 

================================================================= 
48.) The effect of treating herpes zoster with oral acyclovir in preventing 
postherpetic neuralgia. A meta-analysis. 
================================================================= 
Jackson JL; Gibbons R; Meyer G; Inouye L 
Department of Medicine, Madigan Army Medical Center, Tacoma, Wash, USA. 
Arch Intern Med (UNITED STATES) Apr 28 1997 157 (8) p909-12 ISSN: 
0003-9926 
Language: ENGLISH 
Document Type: JOURNAL ARTICLE; META-ANALYSIS 
Journal Announcement: 9707 
Subfile: AIM; INDEX MEDICUS 
BACKGROUND: Herpes zoster is a common affliction in older patients, with 
up to 15% 
experiencing some residual pain in the distribution of the rash several 
months after 
healing. Despite numerous randomized clinical trials, the effect of 
treating herpes 
zoster with oral acyclovir in preventing postherpetic neuralgia remains 
uncertain 
because of conflicting results. METHODS: Meta-analysis of published 
randomized 
clinical trials on the use of acyclovir to prevent postherpetic neuralgia 
using the 
fixed-effects model of Peto. RESULTS: Thirty clinical trials of treatment 
with oral 
acyclovir in immunocompetent adults were identified. After excluding 
studies with 
duplicate data, suboptimal and topical dosing, non-placebo-controlled or 
nonrandomized designs, and those using intravenous acyclovir, 5 trials were 
found to 
be homogeneous and were combined for analysis. From these trials, the 
summary odds 
ratio for the incidence of "any pain" in the distribution of rash at 6 
months in 
adults treated with acyclovir was 0.54 (95% confidence interval, 0.36-0.81). 
CONCLUSION: Treatment of herpes zoster with 800 mg/d of oral acyclovir 
within 72 
hours of rash onset may reduce the incidence of residual pain at 6 months 
by 46% in 
immunocompetent adults. 

================================================================= 
49.) A systematic review of antidepressants in neuropathic pain. 
================================================================= 
McQuay HJ; Tramer M; Nye BA; Carroll D; Wiffen PJ; Moore RA 
Nuffield Department of Anaesthetics, University of Oxford, UK. 
Pain (NETHERLANDS) Dec 1996 68 (2-3) p217-27 ISSN: 0304-3959 
Language: ENGLISH 
Document Type: JOURNAL ARTICLE; META-ANALYSIS 
Journal Announcement: 9706 
Subfile: INDEX MEDICUS 
The objective of this study was to review the effectiveness and safety of 
antidepressants in neuropathic pain. In a systematic review of randomised 
controlled 
trials, the main outcomes were global judgements, pain relief or fall in pain 
intensity which approximated to more than 50% pain relief, and information 
about 
minor and major adverse effects. Dichotomous data for effectiveness and 
adverse 
effects were analysed using odds ratio and number needed-to-treat (NNT) 
methods. 
Twenty-one placebo-controlled treatments in 17 randomised controlled trials 
were 
included, involving 10 antidepressants. In six of 13 diabetic neuropathy 
studies the 
odds ratios showed significant benefit compared with placebo. The combined 
odds 
ratio was 3.6 (95% CI 2.5-5.2), with a NNT for benefit of 3 (2.4-4). In 
two of three 
postherpetic neuralgia studies the odds ratios showed significant benefit, 
and the 
combined odds ratio was 6.8 (3.5-14.3), with a NNT of 2.3 (1.7-3.3). In 
two atypical 
facial pain studies the combined odds ratio for benefit was 4.1 (2.3-7.5), 
with a NNT 
of 2.8 (2-4.7). Only one of three central pain studies had analysable 
dichotomous 
data. The NNT point estimate was 1.7. Comparisons of tricyclic 
antidepressants did 
not show any significant difference between them; they were significantly 
more 
effective than benzodiazepines in the three comparisons available. 
Paroxetine and 
mianserin were less effective than imipramine. For 11 of the 21 
placebo-controlled 
treatments there was dichotomous information on minor adverse effects; 
combining 
across pain syndromes the NNT for minor (noted in published report) adverse 
effects 
was 3.7 (2.9-5.2). Information on major (drug-related study withdrawal) 
adverse 
effects was available from 19 reports; combining across pain syndromes the 
NNT for 
major adverse effects was 22 (13.5-58). Antidepressants are effective in 
relieving 
neuropathic pain. Compared with placebo, of 100 patients with neuropathic 
pain who 
are given antidepressants, 30 will obtain more than 50% pain relief, 30 
will have 
minor adverse reactions and four will have to stop treatment because of 
major adverse 
effects. With very similar results for anticonvulsants it is still unclear 
which 
drug class should be first choice. Treatment would be improved if we could 
harness 
the dramatic improvement seen on placebo in some of the trials. 

================================================================= 
50.) Pain and its persistence in herpes zoster. 
================================================================= 
Dworkin RH; Portenoy RK 
Department of Anesthesiology, Columbia University College of Physicians and 
Surgeons, New York, NY 10032, USA. 
Pain (NETHERLANDS) Oct 1996 67 (2-3) p241-51 ISSN: 0304-3959 
Contract/Grant No.: NS-30714--NS--NINDS 
Language: ENGLISH 
Document Type: JOURNAL ARTICLE; REVIEW; REVIEW, TUTORIAL 
Journal Announcement: 9705 
Subfile: INDEX MEDICUS 
The nature and duration of pain associated with herpes zoster is highly 
variable. 
This review of research on pain in acute herpes zoster and postherpetic 
neuralgia 
(PHN) explores those observations relevant to the definition and 
pathogenesis of PHN 
and the design of treatment trials. A model for the pathogenesis of PHN is 
presented, which gains support from studies of risk factors. Several 
directions for 
future research are identified. (126 References) 

================================================================= 
51.) [Interferon alpha 2b in pain caused by herpes zoster. Preliminary report] 
Interferon alpha 2b en el dolor por herpes zoster. Informe preliminar. 
================================================================= 
Montero Mora P; Colin D; Gonzalez Espinosa A; Almeida Arvizu V 
Departamento de alergia e inmunologia clinica, Hospital de Especialidades 
del 
Centro Medico Nacional Siglo XXI, Mexico D.F. 
Rev Alerg Mex (MEXICO) Nov-Dec 1996 43 (6) p148-51 
Language: SPANISH Summary Language: ENGLISH 
Document Type: 
JOURNAL ARTICLE English Abstract 
Journal Announcement: 9705 
Subfile: INDEX MEDICUS 
We studied forty patients with Zoster Herpes, twenty two of them, with 
this acute 
disease, eighteen with postherpetic neuralgia, to those that were 
considered chronic. 
The evaluation of the effect of INF alpha 2b, in the secondary pain of 
Zoster Herpes 
acute disease, in the patients with chronic severe secondary neuralgia they 
shared; 
the evolution with the treatment for half for visual pain analog scale in 
both groups 
the patients with acute pain, entered for visual pain analog scale between 
10 and two 
points, with medium of 8.2 SD 2.1. They did not find any significance 
difference 
with this values p < 0.6. Most of the patients with acute pain was of 6 a 
0 points 
with the medium a 0.27 y SD: 1,2 in the chronics went from. 6 to 0 points 
with a 
medium of 1.27 (SD:2.4), with a significative difference for t Student for 
comparation the initial scale in final in both groups of (p < 0.0001). The 
comparation of the best days, the disease bettered in acute quicker than 
the chronics 
with significance difference: (p < 0.001). 

================================================================= 
52.) Chronic electrical stimulation of the gasserian ganglion for the 
relief of pain in a series of 34 patients. 
================================================================= 
Taub E; Munz M; Tasker RR 
Division of Neurosurgery, University of Toronto, Ontario, Canada. 
J Neurosurg (UNITED STATES) Feb 1997 86 (2) p197-202 ISSN: 0022-3085 
Language: ENGLISH 
Document Type: JOURNAL ARTICLE 
Journal Announcement: 9704 
Subfile: AIM; INDEX MEDICUS 
The use of an implanted system for chronic electrical stimulation of the 
gasserian 
ganglion for relief of facial pain was described in 1980 by Meyerson and 
H.ANG.akansson. Between 1982 and 1995, the senior author (R.R.T.) performed 
gasserian ganglion stimulation in 34 patients for the relief of chronic 
medically 
intractable facial pain. The etiology of pain was peripheral damage to the 
trigeminal nerve in 22 patients (65%), central (stroke) damage in seven 
(21%), 
postherpetic neuralgia in four (12%), and unclassifiable cause in one (3%). 
All 
patients received a trial of transcutaneous stimulation (Stage 1). 
Successful trials 
in 19 patients (56%) were followed by implantation of a permanent system 
(Stage II). 
Trial and postimplantation stimulation were deemed successful when there 
was a 
reduction of pain by at least 50% whenever the stimulator was on. Success 
rates 
varied from five (71%) of seven patients for central pain to five (23%) of 
22 for 
peripheral pain and none (0%) of four for postherpetic neuralgia. The 
median follow- 
up duration in successful cases was 22.5 months. Infections occurred in 
seven 
patients, all of whom had undergone Stage II treatment. Infections were more 
frequent when the stimulating electrode from Stage I was left in place for 
Stage II 
(six [43%] of 14) than when completely new hardware was used and prophylactic 
antibiotic drugs were administered (one [20%] of five). Other 
complications included 
iatrogenic injury to the trigeminal nerve or ganglion in three cases (9%), 
transient 
diplopia in two (6%), increased pain in two (6%), and various technical 
problems in 
10 (29%). It is concluded that pain of central origin (stroke) is the type 
most 
likely to be relieved by this procedure. This finding is new, as the few 
other 
clinical series reported to date contain no patients with this type of 
pain. The 
risk of infection seems to be lower when completely new hardware is used 
for Stage II 
and prophylactic antibiotic drugs are administered. 


================================================================= 
53.) Systemic corticosteroids do not prevent postherpetic neuralgia. 
================================================================= 
SO - Dermatology 1992;184(4):314-6 
AU - Calza AM; Schmied E; Harms M 
PT - JOURNAL ARTICLE 
AB - We review the use of corticosteroids in preventing postherpetic 
neuralgia (PHN) in a retrospective study over 5 years and 10 months. Out of 
113 patients evaluable, 46 (40%) had PHN. 21 of these 46 patients (38%) had 
received prednisone (p = 0.49; n.s.). Duration and intensity of PHN were 
not different in the prednisone-treated group. This long-term study does 
not support the use of prednisone for preventing PHN. 

================================================================= 
54.) Prevention of post-herpetic neuralgia. Evaluation of treatment with oral 
prednisone, oral acyclovir, and radiotherapy. 
================================================================= 
SO - Int J Dermatol 1991 Apr;30(4):288-90 
AU - Benoldi D; Mirizzi S; Zucchi A; Allegra F 
PT - JOURNAL ARTICLE 
AB - The effects of prednisone, oral acyclovir, and radiotherapy were 
compared with placebo in the prevention of post-herpetic neuralgia. No 
treatment used was able to prevent, with statistical significance, 
post-herpetic neuralgia, although prednisone and acyclovir showed some pain 
reduction in the acute phase. Radiotherapy was of no value in either the 
acute or post-herpetic phase. 


================================================================= 
55.)Postherpetic neuralgia and systemic corticosteroid therapy. Efficacy 
and safety. 
================================================================= 
SO - Int J Dermatol 1990 Sep;29(7):523-7 
AU - Lycka BA 
PT - JOURNAL ARTICLE; META-ANALYSIS 
AB - Corticosteroids are frequently advocated for use in prevention of 
postherpetic neuralgia (PHN), although their use is replete with 
controversy. The present study is a meta-analysis of the four 
well-controlled clinical studies conducted on this issue. The results 
indicated there is a statistically significant decrease in proportions 
affected at 6 and 12 weeks. Standard difference scores were -2.0559 and 
-4.1442, respectively, and 95% confidence intervals were -3.98% to -31.80% 
and -14.16% to -43.84%, respectively. At 24 weeks, no differences were 
detectable between placebo- and corticosteroid-treated groups (SD = 0.6603, 
p greater than 0.05, 95% confidence intervals of -6.78% to 24.67%). Side 
effects of treatment were rare and mild, affecting only 2.5% of patients 
treated with corticosteroids. No patients had dissemination of disease. 
Systemic corticosteroid treatment decreases the proportion of patients 
affected by PHN, especially when it is defined as pain occurring at 6 or 12 
weeks after the acute event. 

================================================================= 
56.) Argon laser induced cutaneous sensory and pain thresholds in 
post-herpetic neuralgia. Quantitative modulation by topical capsaicin. 
================================================================= 
SO - Acta Derm Venereol 1990;70(2):121-5 
AU - Bjerring P; Arendt-Nielsen L; Soderberg U 
PT - JOURNAL ARTICLE 
AB - Sensory and pain thresholds to cutaneous argon laser stimulation were 
determined in patients with post-herpetic neuralgia before and during 
treatment with topical capsaicin. Before treatment both thresholds were 
significantly elevated on the affected side compared to the contralateral 
normal area. After one week of capsaicin treatment both thresholds were 
significantly increased compared to the pre-treatment values, and the 
subjective pain relief, measured on a visual analogue scale (VAS) was 24%. 
More than 10% decrease in VAS pain score was obtained by 62.5% of the 
patients. Laser stimulations at levels at which the sensory and pain 
thresholds are reached were initially described as burning or stinging with 
pain projecting outside the stimulated area. This allodynia to laser 
stimulations changed during capsaicin treatment towards normal sensory and 
pain perception qualities. Both sensory and pain thresholds and the 
subjective pain score evaluated on a visual analogue scale were attenuated 
during the capsaicin treatment, suggesting a significant role of the 
cutaneous sensory and pain receptors in postherpetic neuralgia. 

================================================================= 
57.) Topical capsaicin treatment of chronic postherpetic neuralgia. 
================================================================= 
SO - J Am Acad Dermatol 1989 Aug;21(2 Pt 1):265-70 
AU - Bernstein JE; Korman NJ; Bickers DR; Dahl MV; Millikan LE 
PT - JOURNAL ARTICLE 
AB - Uncontrolled studies have indicated that topically applied capsaicin 
may be a safe and effective treatment for postherpetic neuralgia. In a 
double-blind study 32 elderly patients with chronic postherpetic neuralgia 
were treated with either capsaicin cream or its vehicle for a 6-week 
period. Response to treatment was evaluated by visual analogue scales of 
pain and of pain relief, together with changes in a categoric pain scale 
and in a physician's global evaluation. Significantly greater relief in the 
capsaicin-treated group compared with vehicle was observed for all efficacy 
variables. After 6 weeks almost 80% of capsaicin-treated patients 
experienced some relief from their pain. Because capsaicin avoids problems 
with drug interactions and systemic toxicity, we suggest that topical 
capsaicin be considered for initial management of postherpetic neuralgia. 

================================================================= 
58.) Treatment of chronic postherpetic neuralgia with topical capsaicin. A 
preliminary study. 
================================================================= 
SO - J Am Acad Dermatol 1987 Jul;17(1):93-6 
AU - Bernstein JE; Bickers DR; Dahl MV; Roshal JY 
PT - JOURNAL ARTICLE 
AB - Continuing pain following herpes zoster is common in patients 60 
years of age or older. Current treatments are generally unsatisfactory. The 
endogenous neuropeptide substance P is an important chemomediator of 
nociceptive impulses from the periphery to the central nervous system and 
has been demonstrated in high levels in sensory nerves supplying sites of 
chronic inflammation. In an attempt to alleviate the pain of 14 patients 
with postherpetic neuralgia, capsaicin 
(trans-8-methyl-N-vanillyl-6-nonenamide), known to deplete substance P, was 
applied topically to painful areas of skin for 4 weeks. Of the 12 patients 
completing this preliminary study, 9 (75%) experienced substantial relief 
of their pain. The only adverse reaction was an intermittent, localized 
burning sensation experienced by one patient with application of capsaicin. 
Although these results are preliminary, they suggest that topical 
application of capsaicin may provide a useful approach for alleviating 
postherpetic neuralgia and other syndromes characterized by severe 
localized pain. 

================================================================= 
59.) Prednisolone does not prevent post-herpetic neuralgia. 
================================================================= 
SO - Lancet 1987 Jul 18;2(8551):126-9 
AU - Esmann V; Geil JP; Kroon S; Fogh H; Peterslund NA; Petersen CS; 
Ronne-Rasmussen JO; Danielsen L 
PT - CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL 
AB - In a randomised, double-blind, controlled study of the effect of 
prednisolone on the development of post-herpetic neuralgia 78 patients with 
herpes zoster whose pain and exanthema had been present for less than 96 h 
were given 800 mg acyclovir five times daily for 7 days and prednisolone in 
a total dose of 575 mg, starting with 40 mg daily in the first week and 
tapering off over the next 2 weeks. 18 (23%) of the patients had 
post-herpetic neuralgia at 6 months after the acute zoster, 9 (24.3%) 
having received prednisolone and 9 (22.5%) placebo. The 95% CI for the 
difference between the placebo and prednisolone groups in the proportion of 
patients having pain at 6 months was minus 17% to plus 20%. Prednisolone, 
however, relieved pain for the first 3 days. The 1-2 week interval between 
admission and reappearance of pain and development of triggered pain seems 
to be the time needed to establish neuralgia. Once established, the type 
and intensity of pain remained largely unaltered. 

================================================================= 
60.) Clinical experience with pimozide: emphasis on its use in postherpetic 
neuralgia. 
================================================================= 
SO - J Am Acad Dermatol 1983 Jun;8(6):845-50 
AU - Duke EE 
PT - JOURNAL ARTICLE 
AB - Pimozide has been shown to be effective in the treatment of delusions 
of parasitosis and other monosymptomatic hypochondriacal conditions. In 
this paper it is shown that this benefit may be extended to severe cases of 
neurotic excoriations and to some cases of postherpetic neuralgia 
characterized by pain, paresthesias, and excoriations. 

================================================================= 
61.) Famciclovir for the treatment of acute herpes zoster: effects on acute 
disease and postherpetic neuralgia. A randomized, double-blind, 
placebo-controlled trial. Collaborative Famciclovir Herpes Zoster Study Group. 
================================================================= 
SO - Ann Intern Med 1995 Jul 15;123(2):89-96 
AU - Tyring S; Barbarash RA; Nahlik JE; Cunningham A; Marley J; Heng M; 
Jones T; Rea T; Boon R; Saltzman R 
PT - CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED 
CONTROLLED TRIAL 
AB - OBJECTIVE: To document the effects of treatment with famciclovir on 
the acute signs and symptoms of herpes zoster and postherpetic neuralgia. 
DESIGN: A randomized, double-blind, placebo-controlled, multicenter trial. 
SETTING: 36 centers in the United States, Canada, and Australia. PATIENTS: 
419 immunocompetent adults with uncomplicated herpes zoster. INTERVENTION: 
Patients were assigned within 72 hours of rash onset to famciclovir, 500 
mg; famciclovir, 750 mg; or placebo, three times daily for 7 days. 
MEASUREMENTS: Lesions were assessed daily for as long as 14 days until full 
crusting occurred and then weekly until the lesions healed. Viral cultures 
were obtained daily while vesicles were present. Pain was assessed at each 
of the visits at which lesions were examined and then monthly for 5 months 
after the lesions healed. Safety was assessed throughout the study. 
RESULTS: Famciclovir was well tolerated, with a safety profile similar to 
that of placebo. Famciclovir accelerated lesion healing and reduced the 
duration of viral shedding. Most importantly, famciclovir recipients had 
faster resolution of postherpetic neuralgia (approximately twofold faster) 
than placebo recipients; differences between the placebo group and both the 
500-mg famciclovir group (hazard ratio, 1.7 [95% CI, 1.1 to 2.7]) and the 
750-mg famciclovir group (hazard ratio, 1.9 [CI, 1.2 to 2.9]) were 
statistically significant (P = 0.02 and 0.01, respectively). The median 
duration of postherpetic neuralgia was reduced by approximately 2 months. 
CONCLUSIONS: Oral famciclovir, 500 mg or 750 mg three times daily for 7 
days, is an effective and well-tolerated therapy for herpes zoster that 
decreases the duration of the disease's most debilitating complication, 
postherpetic neuralgia. 

================================================================= 
62.) Peripheral blood mononuclear cells of the elderly contain 
varicella-zoster virus DNA. 
================================================================= 
SO - J Infect Dis 1992 Apr;165(4):619-22 
AU - Devlin ME; Gilden DH; Mahalingam R; Dueland AN; Cohrs R 
PT - JOURNAL ARTICLE 
AB - Peripheral blood mononuclear cells (PBMC) from humans of different 
ages were analyzed for DNA sequences specific for varicella-zoster virus 
(VZV) genes 29 and 62 by polymerase chain reaction (PCR). Neither VZV gene 
was detected in DNA from umbilical cord blood PBMC of 10 infants or from 
blood PBMC of two 3-year-old children. In 22 humans less than 60 years old, 
gene 29 was not detected, and gene 62 was detected in only one subject. In 
33 humans greater than 60 years old, including patients with postherpetic 
neuralgia, PBMC from 4 subjects contained gene 29, 4 contained gene 62, and 
1 contained both genes. The presence of VZV DNA correlated significantly 
with age (P less than .05, chi 2 and logistic regression analysis), but not 
with gender or postherpetic neuralgia. 

================================================================= 
63.) Dehydroemetine therapy for herpes zoster. A comparison with 
corticosteroids. 
================================================================= 
SO - Cutis 1980 Apr;25(4):424-6 
AU - Hernandez-Perez E 
PT - JOURNAL ARTICLE 
AB - A study involving forty patients, all sixty years of age or over, 
compared the use of dehydroemetine in twenty and triamcinolone in twenty 
for the treatment of herpes zoster. Pretreatment evolution was less than 
ten days. Patients treated with dehydroemetine did not experience 
postherpetic neuralgia, and in fourteen pain completely disappeared at the 
end of only one series of treatment, which in four patients consisted of 
only three injections. Postherpetic neuralgia developed in only eight 
patients out of those treated with triamcinolone, and in four pain 
persisted for more than six months. The results of laboratory tests, 
including cardiovascular evaluation, remained normal with both drugs. 

================================================================= 
64.) A randomized trial of acyclovir for 7 days or 21 days with and without 
prednisolone for treatment of acute herpes zoster [see comments] 
================================================================= 
CM - Comment in: N Engl J Med 1994 Mar 31; 330(13):932-4; Comment in: N 
Engl J Med 1994 Aug 18; 331(7):481 
SO - N Engl J Med 1994 Mar 31;330(13):896-900 
AU - Wood MJ; Johnson RW; McKendrick MW; Taylor J; Mandal BK; Crooks J 
PT - CLINICAL TRIAL; JOURNAL ARTICLE; MULTICENTER STUDY; RANDOMIZED 
CONTROLLED TRIAL 
AB - BACKGROUND. Acyclovir given for 7 to 10 days is of proved benefit in 
acute herpes zoster, but studies of its effectiveness in preventing 
postherpetic neuralgia have had conflicting results. The role of 
corticosteroids in the treatment of herpes zoster is also controversial. 
METHODS. We conducted a double-blind, controlled trial in patients with 
acute herpes zoster to determine whether either 21 days of acyclovir 
therapy or the addition of prednisolone offered any improvement over 7 days 
of acyclovir therapy. Patients with a rash of less than 72 hours' duration 
were assigned to receive acyclovir (800 mg orally, five times daily) for 7 
days with either prednisolone or placebo, or acyclovir for 21 days with 
either prednisolone or placebo. Prednisolone therapy was initiated at a 
dose of 40 mg per day and tapered over a three-week period. Patients were 
assessed frequently through day 28 and then monthly through month 6 to 
assess postherpetic neuralgia. RESULTS. Of 400 patients recruited, 349 
completed the study. No significant differences were detected between the 
four groups in the progression of the rash (P 0.1). With steroid therapy, a 
significantly higher proportion of the rash area had healed on days 7 and 
14 (P = 0.02). Pain reduction was greater during the acute phase of disease 
in patients treated with steroids or 21 days of acyclovir (P 0.01 and P = 
0.02, respectively, on day 7; P 0.01 for steroid therapy on day 14). 
However, on follow-up there were no significant differences between any of 
the groups in the time to a first or a complete cessation of pain. The 
steroid recipients reported more adverse events. CONCLUSIONS. In acute 
herpes zoster, treatment with acyclovir for 21 days or the addition of 
prednisolone to acyclovir therapy confers only slight benefits over 
standard 7-day treatment with acyclovir. Neither additional treatment 
reduces the frequency of postherpetic neuralgia. 

================================================================= 
65.) Early vidarabine therapy to control the complications of herpes zoster 
in immunosuppressed patients. 
================================================================= 
SO - N Engl J Med 1982 Oct 14;307(16):971-5 
AU - Whitley RJ; Soong SJ; Dolin R; Betts R; Linnemann C Jr; Alford CA Jr 
PT - CLINICAL TRIAL; CONTROLLED CLINICAL TRIAL; JOURNAL ARTICLE 
AB - We conducted a double-blind, placebo-controlled trial to assess the 
value of vidarabine therapy for the prevention of complications from herpes 
zoster in immunocompromised patients. Of 121 patients with localized herpes 
zoster of 72 hours duration or less, 63 received vidarabine and 58 received 
the placebo. Populations were matched for pertinent characteristics. 
Therapy accelerated cutaneous healing and decreased the rates of cutaneous 
dissemination (from 24 per cent [14 patients] to 8 per cent [5 patients]) 
(P = 0.014); and of zoster-related visceral complications (from 19 per cent 
[11 patients] to 5 per cent [3 patients]) (P = 0.015). therapy also 
decreased the total duration of post-herpetic neuralgia (P = 0.047). 
Patients with lymphoproliferative cancers and those 38 years of age or 
older were at greatest risk for complications and benefited most from 
therapy. There was no serious drug toxicity. We conclude that vidarabine 
therapy, when started within the first three days, is valuable for the 
reduction of complications related to herpes zoster. 

================================================================= 
66.) EMLA. A new and effective topical anesthetic [see comments] 
================================================================= 
CM - Comment in: J Dermatol Surg Oncol 1994 Mar; 20(3):223 
SO - J Dermatol Surg Oncol 1992 Oct;18(10):859-62 
AU - Lycka BA 
PT - JOURNAL ARTICLE; REVIEW (18 references); REVIEW, TUTORIAL 
AB - A eutectic mixture of local anesthetics (EMLA) contains 2.5% 
lidocaine and 2.5% prilocaine in an oil and water emulsion and has been 
found to give effective, safe analgesia on normal and diseased skin, making 
it useful for numerous medical and surgical procedures, such as anesthesia 
for superficial surgery, split-thickness skin grafts, venipuncture, argon 
laser treatment, epilation, and debridement of infected ulcers. Other 
indications have included use in postherpetic neuralgia, hyperhidrosis, 
painful ulcers, and inhibition of itching and burning. To be effective, 
EMLA should ideally be applied to the desired area for at least 1 hour 
under an occlusive dressing. The medication has been approved since May 
1991 in Canada for use on intact skin and has been available in Europe for 
many years. This study discusses the background, efficacy, and current and 
potential uses of EMLA. 

================================================================= 
67.) Response of varicella zoster virus and herpes zoster to silver 
sulfadiazine. 
================================================================= 
SO - Cutis 1986 Dec;38(6):363-5 
AU - Montes LF; Muchinik G; Fox CL Jr 
PT - JOURNAL ARTICLE 
AB - The addition of silver sulfadiazine to cultures of varicella zoster 
virus resulted in inactivation of the viral infectivity. At a concentration 
of 10 micrograms/ml or higher the virus was inactivated after thirty 
minutes exposure at 37 degrees C. Forty-two patients with herpes zoster 
were treated topically with 1 percent silver sulfadiazine cream applied 
four times a day. All patients experienced complete drying of vesicles, 
marked reduction erythema and edema, and striking elimination of pain and 
burning sensation within twenty-four to seventy-two hours. The sooner the 
treatment began after the onset of symptoms, the more dramatic was the 
response. Postherpetic neuralgia was either mild or did not occur. Signs of 
local, systemic, or laboratory-documented toxicity were not observed. 

================================================================= 
68.) Thalidomide: use and possible mode of action in reactional lepromatous 
leprosy and in various other conditions. 
================================================================= 
SO - J Am Acad Dermatol 1982 Sep;7(3):317-23 
AU - Barnhill RL; McDougall AC 
PT - JOURNAL ARTICLE 
AB - The literature concerning the use and possible mode of action of 
thalidomide in reactional lepromatous leprosy and in various other 
conditions is reviewed. Although it has no action against the leprosy 
bacillus, its value in the treatment of the adverse reactions in this type 
of leprosy is well established, many leprologists considering it to be 
superior to any other drug for this purpose. Its efficacy in actinic 
prurigo is also impressive, and there are reports suggesting benefit in 
discoid lupus erythematosus. By contrast, its reported action in a number 
of other conditions, including severe aphthous stomatitis, Behcet's 
syndrome, pyoderma gangrenosum, nodular prurigo, and postherpetic 
neuralgia, needs confirmation in a larger number of cases, backed in some 
instances by clinical trial. The mechanism of action of this drug may be 
related to (1) anti-inflammatory effects, particularly an inhibition of 
neutrophil chemotaxis, (2) immunosuppressive effects, or (3) effects on 
neural tissue. Furthermore, structure-activity studies may allow separation 
of these and other possible effects. This review is in no way intended to 
lend support to the indiscriminate use of a potentially hazardous drug in 
various diseases of unknown cause, but rather to draw attention to a number 
of conditions in which the drug has been found effective. The further 
judicious use of thalidomide or a nonteratogenic analogue, with careful 
observation of results, may contribute to knowledge of the underlying 
pathology in some of these conditions, and possibly also to the mechanism 
of action of the drug itself. 

================================================================= 
69.) Administration of levodopa for relief of herpes zoster pain. 
================================================================= 
SO - JAMA 1981 Jul 10;246(2):132-4 
AU - Kernbaum S; Hauchecorne J 
PT - CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL 
AB - Forty-seven outpatients with herpes zoster, seen within five days of 
onset of the eruption, received ten days' administration of oral levodopa 
and benserazide or placebo in a double-blind controlled study. Both the 
total patient group and high-risk group, eg, those with either ophthalmic 
zoster or those older than 65 years, were analyzed. Both groups were 
comparable in terms of demographic and pathological criteria. Vomiting was 
the only side effect observed in both groups. A significant decrease in 
intensity of pain was seen in the group receiving levodopa from the third 
day, and complete cessation of both pain and sleep disturbances was more 
frequent in the patients. Two months later, postherpetic neuralgia was also 
less frequent in the group that received levodopa. 

================================================================= 
70.) Treatment of zoster and postzoster neuralgia by the intralesional 
injection of triamcinolone: a computer analysis of 199 cases. 
================================================================= 
SO - Int J Dermatol 1976 Dec;15:762-9 
AU - Epstein E 
PT - JOURNAL ARTICLE 
AB - On the basis of this study of 111 patients with herpes zoster and 88 
with postherpetic neuralgia, it is suggested that the intradermal injection 
of triamcinolone in saline is a valuable treatment. Mild complications were 
pain, hemorrhage, abscesses, atrophy, moon face and possibly 
thrombophlebitis. Zoster patients required treatment for about half as long 
as those in previously reported control series. In patients treated for 
active herpes zoster, postzoster neuralgia occurred with about one-third of 
the frequency noted in other series. In postzoster neuralgia, the patient 
was benefited sufficiently in 62.5% of the cases to find that life was 
worth living again. 

================================================================= 
71.) Epidural injection of local anesthetic and steroids for relief of pain 
secondary to herpes zoster. 
================================================================= 
SO - Arch Surg 1978 Mar;113(3):253-4 
AU - Perkins HM; Hanlon PR 
PT - JOURNAL ARTICLE 
AB - We treated 12 cases of cutaneous herpes zoster (HZ) with epidural 
bupivacaine and methylprednisolone acetate. Treatment was effective for HZ 
of less than seven weeks' duration. The course of HZ of greater than three 
months' duration (postherpetic neuralgia) was not improved. The 
administration of epidural bupivacaine plus methylprednisolone acetate was 
no more effective than when bupivacaine alone was used. Epidural injection 
of bupivacaine with or without methylprednisolone acetate is the treatment 
of choice for the pain of cutaneous HZ. 

================================================================= 
72.) 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 Apr;43(4):363-71 

Max MB, Schafer SC, Culnane M, Dubner R, Gracely RH 

Neurobiology and Anesthesiology Branch, National Institute of Dental 
Research, Bethesda, MD 
20892. 

In a randomized, double-blind crossover study, 40 patients with 
postherpetic neuralgia were given 
single oral doses of clonidine, 0.2 mg, codeine, 120 mg, ibuprofen, 800 mg, 
or inert placebo. Pain 
relief and side effects were recorded for 6 hours. Patients reported 
significantly more relief after 
clonidine than after the other three treatments. Codeine and ibuprofen were 
ineffective. Sedation, 
dizziness, and other side effects were more frequent after clonidine (74%) 
or codeine (69%) than 
after placebo (36%) or ibuprofen (28%). Reported pain relief was greater 
during trials in which side 
effects were present. A single, mild side effect was associated with as 
much additional pain relief as 
multiple, severe side effects. Clonidine's superiority to codeine, which 
had a similar incidence of side 
effects, argues for a specific analgesic effect. In addition, side effects 
may have contributed to 
clonidine analgesia, perhaps by suggesting to patients that they had 
received a potent drug. 

================================================================= 
72.) Italian multicentric study on pain treatment with epidural 
spinal cord stimulation. 
================================================================= 
Stereotact Funct Neurosurg 1994;62(1-4):273-8 

Broggi G, Servello D, Dones I, Carbone G 

Istituto Nazionale Neurologico C. Besta, Milano, Italia. 

A multicentric study on the treatment of nonmalignant chronic pain with 
epidural spinal cord 
stimulation (SCS) has been carried out in 32 Italian centers devoted to 
pain therapy. Neurosurgical 
and anesthesiology units participated in this retrospective study. 410 of 
the eligible patients were 
enrolled in the protocol: 48% were male, 52% female. All patients underwent 
a screening test period 
(average 21 days) and 74% underwent the definitive implant. The diagnosis 
was failed back surgery 
syndrome in 45%, reflex sympathetic dystrophy in 15%, phantom limb pain in 
14%, postherpetic 
neuralgia in 8%, peripheral nerve injury in 5%, others 13%. 84% received 
noninvasive unsuccessful 
treatment (10 tensor acupuncture). All had previous pharmacological therapy 
which was not always 
discontinued when SCS took place. Pain assessment had been done with the 
visual analog scale and 
verbal scale both subjectively and by the physician and nurses. 
Neuropsychological profile with 
minimal mental test or MMPI was obtained in 68% of the patients. These 
results were favorable (i.e. 
excellent or good; more than 50% reduction of pain) in 87% of the patients 
at the 3-month 
follow-up, 75% at the 6-month follow-up, 69% at the 1-year follow-up, and 
58% at the 2-year 
follow-up. Complication rate was: dislocation of the electrocatheter 4%, 
technical problems 3%, 
infections of the system 2%. The results will be discussed in correlation 
with the different etiologies of 
the nonmalignant chronic pain syndrome. 

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73.) Postherpetic neuralgia: clinical experience with a 
conservative treatment. 
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Clin J Pain 1989 Dec;5(4):295-300 

Niv D, Ben-Ari S, Rappaport A, Goldofski S, Chayen M, Geller E 

Department of Anesthesia, Tel-Aviv Medical Center, Sackler School of 
Medicine, Tel-Aviv 
University, Israel. 

Ninety-seven consecutive cases of postherpetic neuralgia (PHN) were 
retrospectively reviewed. 
Patients comprised 49 women and 48 men with a mean age of 71.6 years. The 
most common 
painful locations were the chest and upper back (34%), abdomen and lower 
back (25.2%), and 
face (20.2%). Burning pain was the most common type of pain (61.3%). 
Lancinating pain was 
reported by 40% and throbbing pain by 22.6%. Treatments included drugs 
(mainly tricyclic 
antidepressant, anticonvulsant, and neuroleptic drugs), transcutaneous 
electrical nerve stimulation 
(TENS), and dry needling of muscles in the affected dermatomes. Positive 
response to treatment 
occurred in 18.5% of the patients after one visit. In 9.3% of the patients, 
the pain still could not be 
controlled after 10 visits of 2-week intervals. TENS proved to be effective 
in patients whose skin 
sensation was preserved. It was concluded that in most PHN cases, pain can 
be effectively 
controlled by conservative noninvasive therapy. 


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74.) Spinal cord stimulation (SCS) in the treatment of 
postherpetic pain. 
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Acta Neurochir Suppl (Wien) 1989;46:65-6 

Meglio M, Cioni B, Prezioso A, Talamonti G 

Istituto di Neurochirurgia, Universita Cattolica, Roma, Italy. 

SCS is considered to be of poor value in treating postherpetic pain. We 
have retrospectively 
analyzed the results obtained in 10 patients suffering from postherpetic 
neuralgia. An epidural 
electrode was implanted, aiming the tip in a position where stimulation 
could produce paraesthesiae 
over the painful area. At the end of the test period 6 out of 10 patients 
reporting a mean analgesia of 
52.5% underwent a permanent implant. At mean follow-up (15 months) all the 
6 patients were still 
reporting a satisfactory pain relief (74% of mean analgesia). These figures 
remained unchanged at the 
next follow-ups (max 46 months). The result of SCS in our patients, 
although positive in only 60% of 
them, are remarkably stable with time. We therefore recommend a 
percutaneous test trial of SCS in 
every case of postherpetic neuralgia resistent to medical treatment. 

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75.) Postherpetic neuralgia. 
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Neurol Clin 1989 May;7(2):231-48 

Watson CP 

Department of Medicine, Irene Eleanor Smythe Pain Clinic, University of 
Toronto, Ontario, Canada. 

Postherpetic pain persisting 1 month or longer occurs in only a small 
percentage of all patients with 
herpes zoster. In most patients, PHN tends to diminish with time. The 
incidence is, however, directly 
related to age. Any therapeutic claim for prophylaxis or treatment of PHN 
has to be evaluated with 
these observations in mind. There is some information about the pathologic 
features and a concept of 
the pathogenesis can be suggested. There is evidence for an imbalance in 
fiber input (reduced large, 
inhibitory fibers, and intact or increased small, excitatory fibers) to an 
abnormal dorsal horn that may 
contain hypersensitive neurons. Prevention of PHN remains difficult. There 
is evidence that systemic 
steroids exert a preventive effect when employed in the treatment of herpes 
zoster in the 
immunocompetent patient. A reasonable regimen is 60 mg of prednisone 
tapered over 10 to 14 
days. One double-blind, controlled study supports the use of amantadine in 
this situation; this drug is 
an option in patients for whom steroids are contraindicated, such as those 
with peptic ulcer, diabetes 
mellitus or compromised immune function. The dosage of amantadine used in 
this study was 100 mg 
twice daily for a month. Although a number of other therapies have been 
suggested, these remedies 
remain in need of further, more scientific study. For established PHN, 
there is firm support for the 
reduction of pain from severe to mild in two thirds of patients 
administered low doses of amitriptyline 
followed by gradual, small increments. In the age group over 65 years, one 
may use as small a dose 
as 10 mg with an increase of 10 mg every 5 to 7 days. In those younger than 
65, a dose of 25 mg to 
start is reasonable, with increments of 25 mg. Although unproved, the 
addition of a phenothiazine, 
such as fluphenazine, may provide further pain relief. Preliminary studies 
also indicate that topical 
capsaicin may be a useful new treatment. Although widely used, there is no 
good evidence for the 
use of anticonvulsants alone in this disorder. Studies of local anesthetic 
sprays with vibration and 
continuous TENS are uncontrolled, but these modalities may be of some 
merit. One uncontrolled 
study reported benefit from epidural steroids. DREZ lesions are a 
possibility in failed medical cases, 
but other surgical procedures appear to be of little or no use. Although 
the measures described here 
will benefit a number of patients, PHN remains an intractable problem in 
some cases. 

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76.) Treatment of post-herpetic neuralgia and acute herpetic 
pain with amitriptyline and perphenazine. 
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S Afr Med J 1982 Aug 21;62(9):274-5 

Weis O, Sriwatanakul K, Weintraub M 

A fixed-ratio combination of amitriptyline and perphenazine was successful 
in treating 8 of 9 patients 
suffering from post-herpetic neuralgia. Side-effects were minimal. 
Summaries of 4 case histories are 
presented. In addition, 3 patients suffering from severe acute herpetic 
pain were successfully treated 
with the same drug combination. 

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77.) Nontraditional analgesics for the management of 
postherpetic neuralgia. 
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Thompson M, Bones M 

The pathogenesis and clinical manifestations of herpes zoster and 
postherpetic neuralgia and the use 
of nontraditional analgesics in the management of postherpetic neuralgia 
are reviewed. Herpes zoster 
represents the reactivation in an immunocompromised host of dormant 
varicella-zoster virus 
(Herpesvirus varicellae) contracted during a previous episode of 
chickenpox. Fever, neuralgia, and 
paresthesia occur four to five days before skin lesions develop. Acute 
herpes zoster pain usually 
does not last more than two weeks after all skin lesions have healed. 
Postherpetic neuralgia is 
defined as pain that persists in the affected dermatomes after the 
disappearance of all skin crusts. 
The neuralgia can vary from "lightninglike" stabbing pain to constant, 
burning pain with hyperesthesia; 
it can persist for years and is often refractory to traditional analgesic 
therapy. A number of 
nontraditional analgesic agents have been used in the management of 
postherpetic neuralgia. Tricyclic 
antidepressants, especially amitriptyline, have been used alone and in 
combination with 
phenothiazines or anticonvulsants (carbamazepine, phenytoin, valproate 
sodium), with good results. 
The effectiveness of phenothiazines or anticonvulsants as sole therapeutic 
agents has not been 
demonstrated. Although the intralesional administration of corticosteroids 
appears to be beneficial, 
considerable fear about the potential for these agents to precipitate 
widespread viral dissemination 
exists. Positive results have been reported with levodopa, amantadine, and 
interferon, but the role of 
these agents in the prevention of postherpetic neuralgia remains unclear. 
Nontraditional analgesic 
agents are useful in the management of postherpetic neuralgia, but patients 
must be selected and 
monitored appropriately. A tricyclic antidepressant (especially 
amitriptyline) is a reasonable first 
choice. 

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78.) Efficacy of baclofen in trigeminal neuralgia and some 
other painful conditions. A clinical trial. 
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Eur Neurol 1984;23(1):51-5 

Steardo L, Leo A, Marano E 

Baclofen (beta-4-chlorophenyl-gamma-aminobutyric acid) shows analgesic 
properties in rats and 
resembles carbamazepine and phenytoin in its effects on the spinal 
trigeminal nucleus of cats. We 
have, therefore, conducted a clinical trial in 25 subjects, 16 suffering 
from trigeminal neuralgia, and 9 
patients were affected by different painful conditions such as postherpetic 
neuralgia, tabes dorsalis, 
postarachnoid radiculitis. 5 of the former groups were refractory to or 
unable to tolerate 
carbamazepine. Baclofen has significantly exhibited analgesic efficacy: all 
groups, as a whole, were 
improved by 68.61%. These results substantiate that baclofen is useful in 
the treatment of trigeminal 
neuralgia and other painful conditions. 

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79.) Epidural morphine and postherpetic neuralgia [letter] 
Mayne CC; Hudspith MJ; Munglani R 
Anaesthesia (ENGLAND) Dec 1996 51 (12) p1190 ISSN: 0003-2409 
LETTER 
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80.)- Acupuncture and postherpetic neuralgia [letter] 
SO - Br Med J 1980 Aug 30;281(6240):622 
AU - Lewith GT; Field J 
PT - LETTER 
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DATA-MEDICOS/DERMAGIC-EXPRESS No (74) 22/09/99 DR. JOSE LAPENTA R. 
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