REFERENCIAS BIBLIOGRÁFICAS / BIBLIOGRAPHICAL REFERENCES

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A.- Postherpetic Neuralgia.(2014)

B.-Therapeutic Strategies for Postherpetic Neuralgia: Mechanisms, Treatments, and Perspectives.(2023)

C.- Interventional Treatments for Postherpetic Neuralgia: A Systematic Review.(2019)

D.- Neurontin. FDA Drug Label (2010).

E.- Comparison of the Efficacy of Pulsed Radiofrequency in Treating Acute Herpetic Neuralgia and Postherpetic Neuralgia in the Thoracic Segment.(2024)

F.- The Efficacy of Pregabalin for Acute Pain Control in Herpetic Neuralgia Patients: A Meta-Analysis.

G.- Topical Capsaicin (High Concentration) for Chronic Neuropathic Pain in Adults (2017).

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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] 

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1.) Comparative therapeutic evaluation of intrathecal versus epidural  methylprednisolone for long-term analgesia in patients with intractable  postherpetic neuralgia. 

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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. 

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2.) Patient-controlled epidural analgesia for postherpetic neuralgia in an  HIV-infected patient as a therapeutic ambulatory modality. 

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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. 

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3.) A trial of intravenous lidocaine on the pain and allodynia of  postherpetic neuralgia. 

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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. 

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4.) Pain and somatosensory dysfunction in acute herpes zoster. 

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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. 

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5.) Topical lidocaine patch relieves postherpetic neuralgia more  effectively than a vehicle topical patch: results of an enriched enrollment  study. 

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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. 

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6.) [Treatment of postherpetic neuralgia by topical application of  prostaglandin E1-vaseline mixture--a single blind controlled clinical trial]. 

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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. 

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7.) Acute herpetic neuralgia and postherpetic neuralgia in the head and  neck: response to gabapentin in five cases. 

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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. 

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8.) HLA-A33 and -B44 and susceptibility to postherpetic neuralgia (PHN). 

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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. ozawa@is.icc.u-tokai.ac.jp 

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. 

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9.) Evaluation of analgesic effect of low-power He:Ne laser on postherpetic  neuralgia using VAS and modified McGill pain questionnaire. 

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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. 

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10/) Iontophoretic vincristine in the treatment of postherpetic neuralgia:  a double-blind, randomized, controlled trial. 

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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. 

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11.) Treatment of postherpetic neuralgia. 

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J Am Pharm Assoc (Wash) 1999 Mar-Apr;39(2):217-21 

Menke JJ, Heins JR 

South Dakota State University, Brookings 57007-0099, USA. 

menke.jennifer_@sioux-falls.va.gov 

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.

V 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. 

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13.) Follow-up of clinical efficacy of iontophoresis therapy for  postherpetic neuralgia (PHN). 

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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. 

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14.) Effect of Ganoderma lucidum on postherpetic neuralgia. 

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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. 

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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. 

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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. 

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16.) Postherpetic neuralgia: the importance of preventing this intractable  end-stage disorder. 

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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. 

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17.) Postherpetic neuralgia: impact of famciclovir, age, rash severity, and  acute pain in herpes zoster patients. 

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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. dwrkn@troi.cc.rochester.edu 

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. 

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18.) The identification of risk factors associated with persistent pain  following herpes zoster. 

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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. RWhitley@peds.uab.edu 

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. 

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19.) Gabapentin for the treatment of postherpetic neuralgia: a randomized  controlled trial. 

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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. 

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20.) [Clinical course and treatment of herpetic trigeminal ganglionic  neuropathy]. 

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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. 

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21.) Unilateral postherpetic neuralgia is associated with bilateral sensory  neuron damage. 

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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. 

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22.) CSF and MRI findings in patients with acute herpes zoster. 

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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. 

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23.) In vitro activity of acetylsalicylic acid on replication of  varicella-zoster virus. 

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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. 

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24.) Herpes zoster in children and adolescents. 

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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. 

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25.) Oral corticosteroids for pain associated with herpes zoster. 

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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. michael-ernst@uiowa.edu 

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. 

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26.) Toxic effects of capsaicin on keratinocytes and fibroblasts. 

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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. 

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27.) Gamma knife treatment of trigeminal neuralgia: clinical and  electrophysiological study. 

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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. 

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28.) Nortriptyline versus amitriptyline in postherpetic neuralgia: a  randomized trial. 

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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. 

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29.) [Lidocaine tape (Penles--a dressing tape based on 60% lidocaine-)  reduces the pain of postherpetic neuralgia]. 

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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. 

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30.) Postherpetic neuralgia: irritable nociceptors and deafferentation. 

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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. 

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31.) The caudalis DREZ for facial pain. 

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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. 

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32.) DREZ coagulations for deafferentation pain related to spinal and  peripheral nerve lesions: indication and results of 79 consecutive procedures. 

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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). 

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33.) Jaipur block in postherpetic neuralgia. 

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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. 

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34.) Efficacy of oxycodone in neuropathic pain: a randomized trial in  postherpetic neuralgia. 

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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. 

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35.) Intracutaneous histamine injection can detect damage of cutaneous  afferent fibres in postherpetic neuralgia. 

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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. 

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36.) The management of postherpetic neuralgia. 

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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. 

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37.) The "three-in-one block" for treatment of pain in a patient with acute  herpes zoster infection. 

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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. 

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38.) Use of gabapentin in pain management. 

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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. 

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39.)Peppers and pain. The promise of capsaicin. 

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Drugs 1997 Jun;53(6):909-14 

Fusco BM, Giacovazzo M 

Department of Clinical Medicine, University La Sapienza, Rome, 1taly. 

bmfusco@mbox.vol.it 

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. 

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40.) Economic evaluation of famciclovir in reducing the duration of  postherpetic neuralgia. 

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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. 

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41.) The effects of pre-emptive treatment of postherpetic neuralgia with  amitriptyline: a randomized, double-blind, placebo-controlled trial. 

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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. 

V ================================================================= 

42.) Persistence of varicella-zoster virus DNA in elderly patients with  postherpetic  neuralgia. 

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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. 

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43.) Risk factors for postherpetic neuralgia [see comments] 

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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. 

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44.) Deep brain stimulation for intractable pain: a 15-year experience. 

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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) 

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45.) [Treatment of post-herpes zoster pain with tramadol. Results of an  open pilot study  versus clomipramine with or without levomepromazine] 

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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, 

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46.) High-dose oral dextromethorphan versus placebo in painful diabetic  neuropathy and postherpetic neuralgia. 

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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. 

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47.) Herpes zoster and postherpetic neuralgia. Optimal treatment. 

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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) 

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48.) The effect of treating herpes zoster with oral acyclovir in preventing  postherpetic neuralgia. A meta-analysis. 

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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. 

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49.) A systematic review of antidepressants in neuropathic pain. 

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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. 

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50.) Pain and its persistence in herpes zoster. 

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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) 

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51.) [Interferon alpha 2b in pain caused by herpes zoster. Preliminary report]  Interferon alpha 2b en el dolor por herpes zoster. Informe preliminar. 

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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). 

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52.) Chronic electrical stimulation of the gasserian ganglion for the  relief of pain in a series of 34 patients. 

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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. 

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53.) Systemic corticosteroids do not prevent postherpetic neuralgia. 

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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. 

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54.) Prevention of post-herpetic neuralgia. Evaluation of treatment with oral  prednisone, oral acyclovir, and radiotherapy. 

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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. 

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55.)Postherpetic neuralgia and systemic corticosteroid therapy. Efficacy  and safety. 

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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. 

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56.) Argon laser induced cutaneous sensory and pain thresholds in  post-herpetic neuralgia. Quantitative modulation by topical capsaicin. 

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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. 

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57.) Topical capsaicin treatment of chronic postherpetic neuralgia. 

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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. 

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58.) Treatment of chronic postherpetic neuralgia with topical capsaicin. A  preliminary study. 

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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. 

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59.) Prednisolone does not prevent post-herpetic neuralgia. 

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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. 

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60.) Clinical experience with pimozide: emphasis on its use in postherpetic  neuralgia. 

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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. 

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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. 

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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. 

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62.) Peripheral blood mononuclear cells of the elderly contain  varicella-zoster virus DNA. 

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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. 

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63.) Dehydroemetine therapy for herpes zoster. A comparison with  corticosteroids. 

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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. 

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64.) A randomized trial of acyclovir for 7 days or 21 days with and without  prednisolone for treatment of acute herpes zoster [see comments] 

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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. 

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65.) Early vidarabine therapy to control the complications of herpes zoster  in immunosuppressed patients. 

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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. 

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66.) EMLA. A new and effective topical anesthetic [see comments] 

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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. 

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67.) Response of varicella zoster virus and herpes zoster to silver  sulfadiazine. 

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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. 

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68.) Thalidomide: use and possible mode of action in reactional lepromatous  leprosy and in various other conditions. 

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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. 

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69.) Administration of levodopa for relief of herpes zoster pain. 

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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. 

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70.) Treatment of zoster and postzoster neuralgia by the intralesional  injection of triamcinolone: a computer analysis of 199 cases. 

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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. 

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71.) Epidural injection of local anesthetic and steroids for relief of pain  secondary to herpes zoster. 

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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. 

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72.) Association of pain relief with drug side effects in  postherpetic neuralgia: a single-dose study of clonidine,  codeine, ibuprofen, and placebo. 

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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. 

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72.) Italian multicentric study on pain treatment with epidural  spinal cord stimulation. 

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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-MÉDICOS/DERMAGIC-EXPRESS No (72) 22/09/99 DR. JOSÉ LAPENTA R. 

UPDATED 09 JUNE 2025

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Produced by Dr. José Lapenta R. Dermatologist

Venezuela 1.998-2.025

Producido por Dr. José Lapenta R. Dermatólogo Venezuela 1.998-2.025

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