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Herpes zoster, or shingles, is a painful blistering rash caused by reactivation of the herpes varicella-zoster virus. Herpes zoster can occur in childhood but is much more common in adults, especially the elderly, sick or immune suppressed. The first sign of herpes zoster is usually pain, which may be severe, in the areas of one or more sensory nerves, often where they emerge from the spine.
Post-herpetic neuralgia is defined as persistence or recurrence of pain more than a month after the onset of shingles. The chosen drug should be stopped if it does not produce the desired effect or causes unacceptable side effects at appropriate dose and duration. Amitriptyline, imipramine, dothiepin, clomipramine, desipramine and doxepin have been shown to have analgesic effects in patients with neuropathic pain, independent of their antidepressant action. Tricyclics may also have analgesic effect when used topically, but no topical formulation is available in New Zealand. Although SSRIs have some analgesic properties and are safer, they appear to be less effective than the tricyclics.
These have widely differing methods of action so it is logical to try other agents if the first is unsuccessful.
Gabapentin may have an action on the alpha delta 2 subunit of a calcium channel and inhibit glutamate release.


It is infectious, resulting in chickenpox in those who have never developed primary immunity, both from virus in the lesions and in some instances the nose and throat.
In uncomplicated cases recovery is complete in 2-3 weeks in children and young adults, and 3 to 4 weeks in older patients. Polypharmacy can be useful to allow lower doses to achieve analgesia but side effects and drug interactions can be risky. More potent opioids are sometimes required short term, but can result in escalating dose requirements. They have an effect on the inhibitory serotonergic pathway, noradrenergic pathway, sodium channels, NMDA receptors and adenosine receptors. In doses of up to 500 mg bd it is associated with many adverse effects including severe allergic rashes (toxic epidermal necrolysis), hepatic enzyme induction, hyperlipidaemia, hyponatraemia and weight gain.
Like herpes simplex, the virus persists in selected cells of dorsal root ganglion before it is reactivated. Within one to three days of the onset of pain, crops of closely grouped erythematous papules develop within the unilateral dermatome(s).
Muscle weakness arises in about one in twenty patients because the motor nerves are affected as well as the sensory nerves. Anticholinergic effects include dry mouth, blurred vision, constipation, urinary hesitancy, tachycardia and ejaculatory difficulty.


The dose should be very slowly increased over six weeks up to 400mg once daily, to reduce the risk of skin rash. New papules continue to appear for several days, each blistering or becoming pustular then crusting over. The pain may be continuous and burning with increased sensitivity in the affected areas, or a spasmodic shooting type, or, rarely, itching and crawling (formication). As there are differing adverse effects, it is sometimes worth trying several different agents. There is a 50% chance of complete recovery and in time some improvement can be expected in nearly all cases.
The overlying skin is numb or exquisitely sensitive to touch (hyperaesthesia and allodynia). Other side effects include dry mouth, peripheral oedema, weight gain, abnormal gait, amnesia, confusion, hypaesthesia, abnormal thinking, dyspnoea, amblyopia.



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Comments
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