Treatment of herpes zoster and postherpetic neuralgia

doi:10.1136/bmj.326.7392.748

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Robert W Johnson, consultant anaesthetist and directora,
Robert H Dworkin, professor of anaesthesiology, neurology, oncology, and psychiatryb

^a Pain Management Clinic, Bristol Royal Infirmary, Bristol BS2 8HW
^b University of Rochester Medical Centre, New York, USA

Postherpetic neuralgia after herpes zoster can considerably affect quality of life. The current treatment options are discussed here

Herpes zoster (shingles) affects up to half of all people who live to 85 years of age and can lead to long term morbidity. Appropriate treatment controls acute symptoms and reduces the risk of longer term complications. The most common complication in immunocompetent patients is distressing and sometimes intractable chronic pain. Prevention and treatment should be priorities. Most cases of zoster can be managed in primary care and a full understanding of the condition is essential. A previous BMJ editorial focused on variability of estimates of prevalence.1 Here we present an update on the treatment of herpes zoster and postherpetic neuralgia.

Summary points

Appropriate treatment of herpes zoster can control acute symptoms and reduce the risk of longer term complications

Knowledge of risk factors for postherpetic neuralgia can provide a rationale for their prevention

Most cases of zoster and postherpetic neuralgia can be managed in primary care

What is herpes zoster?

Herpes zoster results from recrudescence of latent varicella zoster virus from dorsal root or cranial nerve ganglia, present since primary infection with varicella (chicken pox).2 After the primary infection the virus is probably often reactivated, but competent cell mediated immunity prevents clinical disease. These asymptomatic reactivations and contact with people with varicella may enhance immunity.3 In temperate climates varicella is usually a childhood disease, but in tropical climates, particularly in isolated communities, it is more common in adolescents or adults; in either case zoster may follow. The incidence of zoster in community samples ranges from 1.2-3.4 per 1000 person years.4 At an incidence of 2/1000, about 500 000 cases annually would occur in the United States and about half this number in the United Kingdom.2 The incidence rises steeply with age, being …