Materiały źródłowe

• #1 Diagnosing and Managing Postherpetic Neuralgia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3693437/

  Postherpetic neuralgia (PHN) represents a potentially debilitating and often undertreated form of neuropathic pain that disproportionately affects vulnerable populations, including the elderly and the immunocompromised. […] Diagnosis of PHN requires consideration of recognized PHN signs and known risk factors, including advanced age, severe prodromal pain, severe rash, and AHZ location on the trigeminal dermatomes or brachial plexus. […] Although AHZ is typically easily recognizable, PHN can be difficult to diagnose because a patient with pain long after the AHZ rash has cleared up may not remember the rash or associate the current pain with it. […] In the diagnosis of PHN, routine questioning should attempt to identify the nature of the patients pain. […] Pain following a documented episode of AHZ provides compelling evidence for a diagnosis of PHN.

• #2

  https://link.springer.com/article/10.1007/s40266-012-0014-3

  Postherpetic neuralgia (PHN) represents a potentially debilitating and often undertreated form of neuropathic pain that disproportionately affects vulnerable populations, including the elderly and the immunocompromised. […] Diagnosis of PHN requires consideration of recognized PHN signs and known risk factors, including advanced age, severe prodromal pain, severe rash, and AHZ location on the trigeminal dermatomes or brachial plexus. […] Although the symptoms of AHZ typically resolve within 24 weeks, approximately 10 % of patients develop postherpetic neuralgia (PHN), often defined as pain persisting more than 3 months after the onset of the rash in the same affected area. […] Pain following a documented episode of AHZ usually provides clear evidence for a diagnosis of PHN. […] In the diagnosis of PHN, routine questioning should attempt to identify the nature of the patients pain.

• #3 Postherpetic Neuralgia – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK493198/

  Postherpetic neuralgia (PHN) is the most common long-term complication of varicella-zoster virus (VZV) reactivation. […] The hallmark of PHN is a lancinating/burning pain in a unilateral dermatomal pattern that persists for three or more months after the onset of a herpes zoster (HZ) outbreak. […] Unlike other neuropathic conditions, the diagnosis of postherpetic neuralgia is relatively straightforward and not one of exclusion. […] Persistent (more than or equal to 3 months) lancinating/burning pain, allodynia, paresthesias, pruritus, dysesthesias, and/or hyperalgesia at or near the area of the rash is characteristic of PHN. […] Postherpetic neuralgia is almost universally diagnosed based on history and physical. […] However, laboratory tests and some targeted imaging may provide a degree of utility.

• #4 Herpes Zoster and Postherpetic Neuralgia: Prevention and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2017/1115/p656.html

  Herpes zoster, or shingles, is caused by reactivation of varicella zoster virus, which causes chickenpox. […] Postherpetic neuralgia is the most common complication, occurring in about one in five patients. It is defined as pain in a dermatomal distribution sustained for at least 90 days after acute herpes zoster. […] Although herpes zoster typically is diagnosed clinically, if laboratory confirmation is needed, polymerase chain reaction testing of vesicle or other fluids is preferred for diagnosis because of its high sensitivity (95%) and specificity (100%). […] The diagnosis of herpes zoster is typically clinical. Although herpes zoster is difficult to identify during the prodrome, the appearance of the typical exanthem aids in diagnosis. Testing is typically not needed, but it may be considered in patients with recurring lesions that are suspicious for herpes simplex, or in those with suspected zoster sine herpete, in which the virus causes pain without lesions.

• #5 Post-herpetic neuralgia

  https://dermnetnz.org/topics/post-herpetic-neuralgia

  Post-herpetic neuralgia is defined as pain after and caused by, re-activation of the herpes zoster virus, evidence of herpes zoster infection is critical for diagnosis. […] Usually, the diagnosis of herpes zoster is easily made when a painful blistering rash arises that has dermatomal distribution (ie, along the pathway of a cutaneous nerve). […] However, not all patients with post-herpetic neuralgia have a history of rash or acute symptoms. In these cases, a rise in antibody levels on serial blood tests may confirm the previous infection by herpes zoster virus. […] Post-herpetic neuralgia is often used to describe any pain that persists after herpes zoster blisters have cleared up. […] Some experts prefer to reserve the term only for pain that lasts for more than 28 days or more than 120 days.

• #6 Post-herpetic neuralgia

  https://dermnetnz.org/topics/post-herpetic-neuralgia

  ’Acute’ and 'sub-acute’ herpetic neuralgia may be used to describe earlier pain associated with herpes zoster infection. […] The duration of post-herpetic neuralgia is variable. […] In the majority of people, symptoms resolve within 6 months to 1 year. […] In untreated patients, about half have no pain at 6 months. […] Some people have pain lasting for many years, sometimes several decades. […] The duration and severity of neuralgia increase with age.

• #7 Postherpetic Neuralgia | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/27517

  Postherpetic neuralgia occurs in a subset of the population suffering from an episode of acute HZ. […] Well-established risk factors for an acute HZ episode progressing to PHN include age, severe immunosuppression, the presence of a prodromal phase, severe pain during zoster outbreak, allodynia, ophthalmic involvement, and diabetes mellitus. […] Unlike other neuropathic conditions, the diagnosis of postherpetic neuralgia is relatively straightforward and not one of exclusion. […] Therefore, a history of rash with blisters in a dermatomal pattern could be established. […] Persistent (more than or equal to 3 months) lancinating/burning pain, allodynia, paresthesias, pruritus, dysesthesias, and/or hyperalgesia at or near the area of the rash is characteristic of PHN. […] Postherpetic neuralgia is almost universally diagnosed based on history and physical.

• #8

  https://www.painscale.com/article/diagnosing-postherpetic-neuralgia

  Postherpetic neuralgia is a painful condition that can develop as a medical complication of shingles (herpes zoster virus). It presents as a burning pain in the nerves and skin after the rash and blisters from the shingles virus have healed. […] Individuals experiencing severe pain in the same location where the shingles rash was located will most likely be diagnosed as having postherpetic neuralgia. A misdiagnosis of postherpetic neuralgia is rare. A health care professional bases the diagnosis of postherpetic neuralgia on an individuals symptoms; further testing is not usually necessary. The diagnostic process typically includes the following: Examining the skin, Determining the border of the affected area, Obtaining a medical history, Clarifying the time frame of the pain, Identifying symptoms (burning, aching, shooting or stinging pain; touch sensitivity; itching or numbness). […] After receiving a postherpetic neuralgia diagnosis, several treatment options are available; however, complete healing may take months or years.

• #9 Post-herpetic neuralgia: Diagnosis and management options – Medical Independent

  https://www.medicalindependent.ie/societies/isr/post-herpetic-neuralgia-diagnosis-and-management-options/

  The diagnosis of PHN is relatively straightforward and not one of exclusion. An episode of HZ is a prerequisite for PHN. Therefore, a history of rash with blisters in a dermatomal pattern would be expected. Rarely the characteristic rash will not be found. Persistent (more than or equal to three months) lancinating/burning pain, allodynia, paraesthesia, pruritus, dysesthesia, and/or hyperalgesia at or near the area of the rash is characteristic of PHN. […] PHN is almost universally diagnosed based on the history and physical examination. However, laboratory tests and some targeted imaging may provide a degree of utility. These are of greater value in atypical presentations of PHN, such as zoster sine herpete or HZ of the larynx. […] A four-fold rise has been used to diagnose subclinical HZ (zoster sine herpete). However, this rising titre may or may not be secondary to viral exposure or reactivation. Comparatively, immunofluorescence of vesicle scrapings detects VZV antigens in a highly specific and sensitive manner. Similarly, PCR is exquisitely sensitive for the detection of VZV DNA.

• #10

  https://link.springer.com/article/10.1007/s40266-012-0014-3

  The patient history may reveal conditions that may help differentially diagnosis PHN, including a recent history or the presence of herpes simplex virus, impetigo, candidiasis, contact dermatitis, insect bites, autoimmune blistering disease, dermatitis herpetiformis and drug-related eruptions. […] Nevertheless, pain following a documented episode of AHZ usually provides clear evidence for a diagnosis of PHN. […] During the physical examination, areas of previous AHZ may show evidence of cutaneous scarring. […] In approximately 50 % of patients with PHN, dynamic mechanical allodynia occurs in the pain-producing area in response to normally nonpainful stimuli, such as light touch by a brush. […] However, in some cases, decreased sensation or numbness may be experienced by the patient.

• #11 Diagnosing and Managing Postherpetic Neuralgia

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3693437/

  This evidence may be particularly compelling when additional PHN risk factors are present, including advanced age, severe prodromal pain, severe rash, AHZ localized in the trigeminal dermatomes and brachial plexus, and symptoms of allodynia. […] The patient history may reveal conditions that may help differentially diagnosis PHN, including a recent history or the presence of herpes simplex virus, impetigo, candidiasis, contact dermatitis, insect bites, autoimmune blistering disease, dermatitis herpetiformis and drug-related eruptions. […] In approximately 50 % of patients with PHN, dynamic mechanical allodynia occurs in the pain-producing area in response to normally nonpainful stimuli, such as light touch by a brush. […] However, in some cases, decreased sensation or numbness may be experienced by the patient.

• #12 Postherpetic neuralgia – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/postherpetic-neuralgia/diagnosis-treatment/drc-20376593

  Your health care provider will check your skin. They might touch the skin in different places to find the borders of the affected area. […] In most cases, no tests are needed. […] For postherpetic neuralgia, questions to ask your doctor include: How long might my symptoms last? What treatment do you suggest? And are there other choices? […] Your doctor is likely to ask you questions such as: Do your symptoms happen some or all the time? How bad are your symptoms? Have you had chickenpox? When? Have you had a shingles vaccine? What, if anything, seems to improve your symptoms? What, if anything, seems to make your symptoms worse?

• #13 Postherpetic Neuralgia – Novus Spine & Pain Center

  https://novusspinecenter.com/pain-conditions/postherpetic-neuralgia

  Postherpetic neuralgia is a condition of recurring or persistent pain in an area of the body that has undergone an outbreak shingles (the herpes zoster virus). […] The diagnoses of the majority of patients with postherpetic neuralgia is during a follow-up of a recent shingles infection. During an examination of your skin, the doctor may touch it in places to determine the borders of the affected area. […] In most cases, no special tests are necessary.

• #14 Postherpetic Neuralgia – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK493198/

  A four-fold rise has been used to diagnose subclinical HZ (zoster sine herpete). […] Small-scale studies suggest that magnetic resonance imaging (MRI) may hold promise for diagnosing challenging PHN cases and differentiating between PHN and HZ. […] The first is prevention, which focuses on identifying populations at risk for contracting HZ and administering a vaccine. […] The second is early recognition and treatment of an acute HZ infection, as delay may increase the chance of developing PHN. […] The third approach is symptom management of PHN via multimodal medication regimens and interventional procedures. […] Traditional non-invasive treatments include oral and topical medications. […] The American Academy of Neurology (AAN), Special Interest Group on Neuropathic Pain (NeuPSIG), and European Federation of Neurological Societies (EFNS) all recommend an oral tricyclic antidepressant (TCA), pregabalin, and the lidocaine 5% patch as first-line therapies.

• #15 Postherpetic Neuralgia Workup: Laboratory Studies, Imaging Studies, Histologic Findings

  https://emedicine.medscape.com/article/1143066-workup

  In most cases of postherpetic neuralgia (PHN), no laboratory work is necessary. […] Evaluation of cerebrospinal fluid (CSF) yields abnormal findings in 61% of patients. Pleocytosis is observed in 46%, elevated protein in 26%, and varicella zoster virus (VZV) DNA in 22%. However, these findings do not predict the clinical course of PHN. […] Viral culture or immunofluorescent staining may be used to differentiate herpes simplex virus (HSV) infection from herpes zoster (HZ) in cases where it is difficult to distinguish the two conditions from each other on clinical grounds. […] Antibodies to VZV can be measured. A fourfold increase in these antibodies has been used to support the diagnosis of subclinical HZ (zoster sine herpete). However, a rising titer that is secondary to viral exposure rather than reactivation cannot be ruled out.

• #16 Acute Herpes Zoster and Postherpetic Neuralgia | PM&R KnowledgeNow

  https://now.aapmr.org/acute-herpes-zoster-and-post-herpetic-neuralgia/

  PHN presents as neuropathic pain with a burning, throbbing, sharp, and/or shooting nature. Tactile allodynia is the most debilitating sign. PHN usually occurs in the same dermatome as the preceding vesicular eruption. A secondary musculoskeletal component can occur as a result of muscle spasm in response to acute pain, or actual motor weakness caused by (rare) involvement of anterior horn cells. […] Laboratory studies are not required to establish the diagnosis. Serology is typically not indicated. In cases where definitive clinical diagnosis cannot be made (i.e., atypical rash or disseminated disease without cutaneous lesions in an immunocompromised host), VZV polymerase chain reaction (PCR) is preferred over VZV direct fluorescent antibody staining of early vesicular lesions. Skin biopsy can also be considered. Pain in the absence of a rash may indicate the need to evaluate the patient for other causes such as radiculopathy or plexopathy. […] In PHN, there can be absence of a pain-free period after the initial rash, or there may be a quiescent period of up to 12 months following the rash, after which pain returns. History of rash may not always be present. In such cases, establishing diagnosis may require serial immunologic assays.

• #17 Herpes Zoster and Postherpetic Neuralgia: Prevention and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2017/1115/p656.html

  Testing may also be considered in atypical presentations, such as the widely disseminated lesions that may occur in immunocompromised patients. […] Polymerase chain reaction testing of vesicle or other body fluids is preferred because of its high sensitivity and specificity (95% and 100%, respectively) and short turnaround (typically one day). […] Postherpetic neuralgia, the most common complication of herpes zoster, is defined as pain in a dermatomal distribution that is sustained for at least 90 days after the rash. […] Pain-management strategies should focus on symptom control. Although some patients have complete resolution of symptoms at several years, others continue medications indefinitely.

• #18 Herpes Zoster and Post-Herpetic Neuralgia—Diagnosis, Treatment, and Vaccination Strategies

  https://www.mdpi.com/2076-0817/13/7/596

  Herpes zoster is a clinical diagnosis, especially once the typical cutaneous features are present. However, in immunocompromised patients, the presentation may be atypical. An important differential diagnosis to consider is herpes simplex virus infection. […] When laboratory investigation is indicated, polymerase chain reaction (PCR) testing is preferred (>95% sensitive, 99% specific) and can be used for both cutaneous and non-cutaneous manifestations. Vesicles or erosions seen in cutaneous infections should be swabbed and sent for PCR testing. In non-cutaneous infections, PCR should be performed on the fluids of the organ involvement (e.g., cerebrospinal fluid in meningitis or vitreous samples in acute retinal necrosis). […] The diagnosis of herpes zoster is clinical and can be aided with laboratory investigations. Antivirals should be started early, preferably within 72 h of the onset of herpes zoster to reduce the severity and duration of the condition and decrease the intensity of pain. In patients with a high risk of post-herpetic neuralgia, early initiation of anticonvulsants or tricyclic antidepressants can be considered. […] Procedures such as epidural blocks and subcutaneous or intracutaneous injections of local anesthetics and steroids can be considered for patients with a high risk of PHN to reduce its incidence.

• #19 Postherpetic Neuralgia | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/27517

  However, laboratory tests and some targeted imaging may provide a degree of utility. […] A four-fold rise has been used to diagnose subclinical HZ (zoster sine herpete). […] However, this rising titer may or may not be secondary to viral exposure or reactivation. […] Comparatively, immunofluorescence of vesicle scrapings detects VZV antigens in a highly specific and sensitive manner. […] Similarly, PCR is exquisitely sensitive for the detection of VZV DNA. […] Small-scale studies suggest that magnetic resonance imaging (MRI) may hold promise for diagnosing challenging PHN cases and differentiating between PHN and HZ. […] Three fundamental treatment approaches may be considered for postherpetic neuralgia. […] The first is prevention, which focuses on identifying populations at risk for contracting HZ and administering a vaccine.

• #20 Post-herpetic neuralgia: Diagnosis and management options – Medical Independent

  https://www.medicalindependent.ie/societies/isr/post-herpetic-neuralgia-diagnosis-and-management-options/

  Results of cerebrospinal fluid (CSF) analysis are abnormal in 61 per cent of patients. Pleocytosis, elevated protein, and VZV DNA are usually seen. Viral culture or immunofluorescent staining helps distinguish herpes simplex from HZ. […] Small-scale studies suggest that MRI may hold promise for diagnosing challenging PHN cases and differentiating between PHN and HZ. A study by Haanpaa et al reported that MRI revealed lesions attributable to HZ in the cervical cord and the brain stem in nine patients (56 per cent). At three months after the onset of HZ, PHN developed in five patients (56 per cent) who had an abnormal MRI. On MRI, seven patients with no HZ lesions did not develop residual pain.

• #21 Postherpetic Neuralgia Workup: Laboratory Studies, Imaging Studies, Histologic Findings

  https://emedicine.medscape.com/article/1143066-workup

  A study by Haanpaa et al revealed the following findings from magnetic resonance imaging (MRI): MRI lesions attributable to HZ were seen in the brainstem and cervical cord in nine (56%) of 16 patients. […] At 3 months after the onset of HZ, five (56%) of the nine patients with an abnormal MRI had developed PHN. […] Of the seven patients who had no HZ-related lesions on MRI, none had residual pain. […] Although HZ symptoms may be confined to a few sensory dermatomes, pathologic changes may be more widespread. Affected ganglia of the spinal or cranial nerve roots are swollen and inflamed with a primarily lymphocytic reaction. Some ganglion cells are swollen while others are degenerated. […] In the months following infection, fibrosis occurs in the ganglia, peripheral nerve, and nerve root. Degeneration occurs in the ipsilateral posterior column.

• #22 Post-herpetic neuralgia – Pathos

  https://www.pathos-journal.com/2024_1_246.html

  Post-herpetic neuralgia (PHN) is of particular interest to the algologist because it can be produced by all the pathogenetic mechanisms of neuropathic pain, singly or variously associated. […] In the chapter of neuropathic pain, post-herpetic neuralgia (PHN) is a very special condition because, far from being a single entity, all the pathogenetic types of neuropathic pain are possible in it, either singly or variously represented, causing the clinical picture to vary in severity, conditioning the prognosis and complicating therapy. […] Clinically, to recognise the pathogenic type of PHN, we can refer to a number of criteria, which are: topographical distribution of pain, presence and type of sensory deficit, presence of allodynia and character of the pain intensity pattern. […] If the topographic distribution of pain is metameric, it is Type II or III PHN. […] Allodynia is present in Type II PHN and not in Type III PHN. […] Finally, if the topographic distribution of pain is plurimetameric, it is Type IV PHN (Central) which is associated with anaesthesia without allodynia because there are no C or A afferents capable of causing it.

• #23

  https://link.springer.com/article/10.1007/s40122-023-00510-4

  Early intervention reduces the incidence of postherpetic neuralgia (PHN). […] There is no clear diagnostic method for neuralgia symptoms manifested before the onset of the rash, which can easily cause misdiagnosis. […] The early diagnosis of herpes zoster neuralgia can reduce misdiagnosis and mistreatment, and timely and effective intervention can significantly reduce the incidence of PHN. […] Early diagnosis of HZ neuralgia before eruption can facilitate timely targeted treatment, thereby reducing the incidence of PHN. […] Proteomic quantitative analysis and validation results can serve as a simple, micro, rapid, and accurate diagnostic method. […] Patients with HZ require prompt diagnoses and treatment to avoid severe progression to postherpetic neuralgia (PHN). […] Misdiagnosis not only increases the patients pain, medical expenses, and mental burden, but more importantly, delays the valuable time for early treatment of shingles and increases the risk of complications and PHN.

• #24 Herpes Zoster and Postherpetic Neuralgia: Practical Consideration for Prevention and Treatment

  https://www.epain.org/journal/view.html?doi=10.3344/kjp.2015.28.3.177

  Herpes zoster (HZ) is characterized by a painful rash in the affected dermatome. Postherpetic neuralgia (PHN) is the most troublesome side effect associated with HZ. […] Early diagnosis and treatment with antiviral agents plus intervention treatments is believed to shorten the duration and severity of acute HZ and reduce the risk of PHN. […] The frequency of PHN has been reported to be from 10% to 34% depending on its definition. […] The well-defined risk factors for PHN in patients with HZ include older age, the presence of prodromal pain, the extent and severity of rash, and the severity of acute HZ pain. […] Diagnostic laboratory tests for HZ include polymerase chain reaction (PCR) assay, skin biopsy, immunofluorescence assay, and viral isolation. These tests are useful for patients with atypical lesions such as herpes simplex, as well as those with contact dermatitis and rash. […] Early diagnosis of HZ and treatment with antiviral agents plus interventional treatments can shorten the duration and intensity of pain from HZ and prevent the incidence of PHN.

• #25

  https://link.springer.com/article/10.1007/s40122-023-00510-4

  Clinicians and researchers have attempted to solve the problems of the early diagnosis of herpetic neuralgia using laboratory diagnostic methods, infrared thermography, and high-frequency ultrasound diagnosis. […] However, most of the previous reviews on the diagnosis of herpes zoster only describe PCR and antibody detection methods, which is not comprehensive enough. […] The proteomic quantitative analysis and validation results described in this paper provide a simple, microscopic, rapid, and accurate diagnostic method that allows researchers to conduct further studies and identify proteins that can recognize shingles before the rash appears. […] High-frequency ultrasound diagnosis can detect pathological changes, such as demyelination or edema of the affected nerve roots, and combined with clinical symptoms, it can improve the accuracy of diagnosis. […] At present, most of the clinical proteomic analysis and non-coding RNA research are focused on patients diagnosed with shingles. However, future studies should focus on patients who develop shingles and PHN before the onset of rash.

• #26 Post-herpetic neuralgia – Cancer Therapy Advisor

  https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/hospital-medicine/post-herpetic-neuralgia/

  Post-herpetic neuralgia (PHN) refers to the development of pain in a dermatomal distribution after a varicella zoster infection. […] The diagnosis of PHN is clinical. Confirmatory tests can be performed at the time of an initial zoster infection, including DFA for the herpes virus. However, after the initial infection, diagnosis is based on the symptoms and recent history of herpes zoster. […] A typical patient with PHN is an older patient, either male or female, with history of recent zoster infection, with a neuropathic pain syndrome in a dermatomal distribution, possibly with evidence of scarring from a recent rash. […] Key symptoms: Neuropathic pain syndrome, including burning, anesthesia, and hypersensitivity/allodynia in distribution of prior herpes zoster infection, usually dermatomal. […] Patients at higher risk for development of PHN are older, with more severe pain or rash associated with the initial infection. […] None. Diagnosis is made clinically. […] No radiologic imaging is necessary. […] No need to check any virus antibodies or PCR.

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