Corticosteroids for herpes zoster: what do they accomplish?Mar 06, Author: Acyclovir and its derivatives famciclovir, penciclovir, and valacyclovir have been shown to be safe and effective in the treatment of active disease and the prevention of postherpetic neuralgia PHN. Low-dose gabapentin used in acute herpes zoster did not appear effective in preventing PHN. Antiviral agents fopical a direct antiviral effect on varicella-zoster virus VZV. Nucleoside topical corticosteroids for shingles initially are phosphorylated by viral thymidine kinase, eventually forming a nucleoside triphosphate.
Herpes zoster infection after topical steroid use in the setting of tumid lupus erythematosus
Mar 06, Author: Acyclovir and its derivatives famciclovir, penciclovir, and valacyclovir have been shown to be safe and effective in the treatment of active disease and the prevention of postherpetic neuralgia PHN. Low-dose gabapentin used in acute herpes zoster did not appear effective in preventing PHN. Antiviral agents exert a direct antiviral effect on varicella-zoster virus VZV.
Nucleoside analogues initially are phosphorylated by viral thymidine kinase, eventually forming a nucleoside triphosphate. These molecules inhibit herpes simplex virus HSV polymerase with times the potency of human alpha-DNA polymerase.
The goals of antiviral therapy for herpes zoster are to decrease pain, to inhibit viral replication and shedding, to promote healing of skin lesions, and to prevent or reduce the severity of postherpetic neuralgia.
Antiviral therapy may decrease the length of time for new vesicle formation, the number of days to attain complete crusting, and the days of acute discomfort. Initiate treatment as soon as possible because treatment is most effective within 72 hours of eruption. Treatment with acyclovir is indicated in patients with involvement of the first branch of the trigeminal nerve, those who are immunocompromised, or those with increased risk for major complications from a varicella infection ie, patients older than 13 years, those receiving long-term corticosteroid or aspirin therapy, and those with chronic cutaneous or pulmonary diseases.
Zoster in adolescents may be treated with oral acyclovir if it is initiated within 72 hours of eruption. Famciclovir is a prodrug that, once ingested, is rapidly biotransformed into the active compound penciclovir and phosphorylated by viral thymidine kinase. By competition with deoxyguanosine triphosphate, penciclovir triphosphate inhibits viral polymerase.
Therapy should be initiated as soon as herpes zoster is diagnosed. No data are available on the efficacy of treatment started 72 hours after rash onset. The dosage should be adjusted in patients with renal insufficiency or hepatic disease. Valacyclovir is an L-valyl ester of acyclovir.
Therapy should be initiated at the earliest sign or symptom of herpes zoster; it is most effective when started within 48 hours of the onset of zoster rash. Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. Some authors find benefit in the short-term use of steroids to help manage herpes zoster, and some evidence exists to suggest a decreased incidence of PHN in patients who received steroids.
Other studies find no benefit from the use of steroids. Although steroid use is controversial in herpes zoster, it remains a therapeutic option. Prednisone is inactive and must be metabolized to the active metabolite prednisolone.
Conversion may be impaired in patients with liver disease. The agent is a nonlive, recombinant subunit vaccine intended for intramuscular injection in two doses. It consists of glycoprotein E, an antigen, and AS01B, an adjuvant system, intended to induce a strong and sustained immune response to help overcome reduced immunity that comes with age. It is indicated for the prevention of shingles herpes zoster in adults aged 50 years or older. Vaccines consist of attenuated microorganisms or cellular components, which act as antigens.
VZV vaccines elicit active immunization to increase resistance to infection. Administration stimulates antibody production with specific protective properties. It has been shown to boost immunity against herpes zoster virus shingles in older patients.
It also slightly reduces pain compared with no vaccination in those who develop shingles. The vaccine is indicated for the prevention of herpes zoster in patients who have no contraindications. Topical analgesics containing capsaicin have been shown to be effective for temporary relief of neuropathic pain. Capsaicin is derived from plants of the Solanaceae family. TRPV1 is an ion channel—receptor complex expressed on nociceptive skin nerve fibers.
Topical capsaicin causes initial TRPV1 stimulation that may cause pain, followed by pain relief via a reduction in TRPV1-expressing nociceptive nerve endings. Neuropathic pain may gradually recur over several months, an event thought to be caused by TRPV1 nerve fiber reinnervation of the treated area. Capsaicin is a TRPV1 agonist indicated for neuropathic pain associated with postherpetic neuralgia.
Neuropathic pain may gradually recur over several months; this recurrence is thought to be caused by TRPV1 nerve fiber reinnervation of the treated area. These agents stabilize the neuronal membrane so the neuron is less permeable to ions. This prevents the initiation and transmission of nerve impulses, thereby producing the local anesthetic action. Lidocaine transdermal is indicated for pain associated with postherpetic neuralgia. Pharmacokinetic studies have demonstrated bioequivalence of the 2 patches.
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and facilitate physical therapy. Most oral narcotic analgesics have sedating properties that are beneficial for patients who have skin lesions. Oxycodone is a narcotic analgesic that is indicated for the relief of moderate to severe pain.
Patients with herpes zoster usually experience pain. Antiviral and steroid therapies provide relatively minor relief of pain, and narcotic analgesics are often needed. Acetaminophen is indicated for use in patients with mild pain or fever.
It is the drug of choice for the treatment of pain in patients who 1 have documented hypersensitivity to aspirin or NSAIDs, 2 have upper gastrointestinal GI disease, or 3 are taking oral anticoagulants. Acetaminophen reduces fever via direct action on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.
Ibuprofen is a nonsteroidal anti-inflammatory drug NSAID that is the drug of choice for treatment of mild to moderately severe pain, if no contraindications exist. It inhibits inflammatory reactions and pain, probably by decreasing the activity of the enzyme cyclooxygenase and thereby, in turn, inhibiting prostaglandin synthesis. It inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, an effect that results in a decrease of prostaglandin synthesis.
Although they are most often used as antiepileptics, certain anticonvulsants are also effective for treating neuropathic pain. Gabapentin is a membrane stabilizer, a structural analogue of the inhibitory neurotransmitter gamma-amino butyric acid GABA , which paradoxically is thought not to exert an effect on GABA receptors.
It is used to manage pain and provide sedation in neuropathic pain. Gabapentin is primarily used for the treatment of PHN. It has also been used to treatment the pain of acute zoster. Pregabalin is a structural derivative of GABA. In vitro, it reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function.
Amitriptyline blocks the reuptake of norepinephrine and serotonin. It decreases pain by inhibiting spinal neurons involved in pain perception. Desipramine is a tricyclic antidepressant that, of the first-generation TCAs, has the least adverse effects. These agents have been found to be effective in relieving PHN. Recommendations for the management of herpes zoster. Burden of herpes zoster: Goh CL, Khoo L. A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic.
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