Treatment Guidelines

In summary, the proportion of seropositive individuals in the population will decline as a result of childhood varicella vaccination. In time, this will reduce the incidence of HZ. Adult vaccination has been shown to be effective for the prevention of shingles and PHN.18[II] In acute HZ, early antiviral therapy is recommended and pain treatment with strong opioids, tricyclic anti-depressants, or gabapentin should be considered in addition to conventional analgesics. The pharmacological management of PHN consists of three main classes of oral medication (tricyclic antidepressants, anti-convulsants [calcium channel], opioids), and two categories of topical medications (lidocaine and capsaicin). Possibly because more than one mechanism of PHN operates in most patients, a combination of two or more analgesic agents may produce greater pain relief and fewer side effects. In a recent controlled four-period crossover trial, gabapentin and morphine combined achieved better analgesia at lower doses of each drug than either as a single agent with constipation, sedation, and dry mouth as the most frequent adverse effects.79 A treatment plan for pain associated with HZ is shown in Table 32.3.

Table 32.3 Treatment plan for pain associated with herpes zoster (HZ).

Treatment plan

Prevention of varicella Prevention of HZ and PHN Management of HZ

Management of PHN

Varicella vaccination

HZ vaccination

Psychosocial support

Prompt antiviral drug treatment

Analgesia

Early neuropathic pain treatment Tricyclic antidepressant drugs (TCA)

Anticonvulsants («28 ligands) Opioids

Topical agents Combinations

As child

"Catch-up" as adult Age >60 Immunocompetent

Paracetamol, NSAID

e.g. TCA, opioid or a28 ligand

Nortriptyline

Amitriptyline

Desipramine

Pregabalin

Gabapentin

Tramadol

Oxycodone

Morphine

Lidocaine

Capsaicin

TCA+topical a28 ligandItopical

Opioid Itopical

Opioid1a28 ligand

Opioid1a28 ligandItopical

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