2.6 Postherpetic Neuralgia (from Shingles)
By Trish Elliott, BS; Maria Merlano Gomez; and Julie G. Pilitsis, MD, PhD, MBA (all USA)
Remember that time in your childhood when you and your friends wore mittens and socks on your hands all day? Maybe because your parents brought you to a “Pox Party,” and after sharing a lollipop or chocolate milk, you developed an itch that you couldn’t help but scratch… all over your body… the chicken pox. Before the vaccine was launched in 1995, the chicken pox was a rampant and seemingly inevitable disease among children, with 95% of adults today reporting having had the virus. Although the chicken pox vaccine has decreased the likelihood of the disease, the varicella zoster virus remains dormant in the bodies of those who experienced those 4 to 7 days of itchy agony long ago. Now, the same virus that plagued your body as a child has the potential to reappear, but in a different guise.
Shingles is caused by the reactivation of the chicken pox virus that has been dormant or lying in wait. With it comes the reappearance of a rash. Excessive stress, a weakened immune system, and aging increase the likelihood of virus reactivation. The good news about shingles is that, in contrast to chicken pox, you cannot get it from other people. Postherpetic neuralgia describes the condition in which the nerve pain persists in the area of the shingles rash after the rash has resolved. This can occur in 10% to 20% of patients. There is a higher risk of postherpetic neuralgia in those who have more severe shingles, older folks, or individuals whose shingles occurs on the face. Patients describe the symptoms as stabbing, stinging, or burning. Often, people visibly grimace during pain exacerbations. Individuals with postherpetic neuralgia will avoid touching the sensitive area. If it involves the face, they will try to avoid being out in the wind or in cold weather, or in the summer, they try to avoid being near air-conditioning breezes. They don’t wear scarves or anything that touches the face. Even the light touch of moisturizer, make-up application, or activities such as shaving and washing the face can aggravate the symptoms. A pillow used when sleeping can awaken people if it touches their face.
There is no doubt that Quality of Life can be affected. Aging is, of course, inevitable, but you can decrease the likelihood of postherpetic neuralgia, and if it occurs, its pain intensity. Trust me, I want you to conquer the tennis courts, tend to your tomato garden, hit a hole-in-one on the golf course, or climb Kilimanjaro at your painless leisure. And, yes, staying in shape, being active, and exercising regularly are all parts of your ongoing strategy.
So, let’s discuss this strategy.
The prevention of shingles and the timely identification and management of shingles and/or postherpetic neuralgia are crucial. The absolute best thing you can do to head this off is to get the shingles vaccine! Do this regardless of whether you had chicken pox as a child or not. The vaccine is highly effective and can prevent chances of shingles and its aftereffects. Even if you already have another type of facial pain, this is a wise decision if you are 50 years of age or older. If you do contract shingles, seek immediate care. Antiviral medications can limit the impact and severity of the disease. This is not a time to “gut it out.” Treatment can prevent the dreaded aftermath.
When postherpetic neuralgia does still strike, treatments that are available are similar to those for any other type of nerve pain. Medications include typical nerve pain agents such as gabapentin and pregabalin, anticonvulsants, and antidepressants. In the past, tricyclic antidepressants and opioids were used, and they may be employed in rare cases today. Topical creams with capsaicin, menthol, or lidocaine are other options. Most often, these topical treatments are used in combination with oral medications. Less commonly, nerve blocks of the area with steroids and numbing medicine such as lidocaine may be used.
Integrated care allows for many additive therapies. Diet, meditation, relaxation, and biofeedback are all options. Optimizing hormonal and vitamin status has little downside. Acupuncture-related treatments pose another option for pain relief with few adverse effects. Use of acupuncture with medications holds particular promise, and one study showed that electroacupuncture reduced postherpetic neuralgia-induced insomnia and depression. In cases where these methods do not work, spinal cord stimulation has been successful in a subset of patients. Implanting such a device high in the spine where signals can pass to the brain stem has relieved facial pain in some cases. The stimulation of the device is controlled by the patient using a remote, and the pain is replaced by a light tingling sensation in some cases or no sensation in others. In rare cases, stimulation of the brain regions that affect sensation to the face with deep brain stimulation, motor cortex stimulation, or peripheral stimulation if the pain is in the face may be used. Peripheral stimulation involves insertion of electrodes under the skin of the painful facial regions, specifically, above and below the eye and along the jawline. These work similarly to the electrodes used in spinal cord stimulation when connected to a pacemaker-like device that is also implanted, but usually beneath the collar bone in the chest.
In summary, get vaccinated to prevent getting shingles! See a doctor early if shingles or postherpetic neuralgia does occur. The chicken pox may have scarred your childhood, but do not let this virus affect you in your later years. (The shingles vaccine is available for free in Australia under the National Immunisation Program (NIP) for people aged 65 and older)
