Lymphedema and Shingles

[carolinanightengale]

Can someone tell me, if having lymphedema would make you more susceptible to having shingles?

Thanks!

Melinda

[patoco]

Hi Melinda

Good to see you post

Now remember , I'm not a doctor and these opinions as just my own put together from my understanding of lymphedema and shingles. It isn't meant to replace any advice from your doctor.

First, we need to understand that shingles is caused by the very same virus that is responsible for chicken pox and that is the virus herpes zoster. The virus will remain in your system even after the chicken pox has cleared up and therefore anyone who has had chicken pox is a potential candidate for shingles.

Whether or not an outbreak occurs may depend on several factors.

Perhaps the most important factor is the overall condition of your immune system. Herpes seems to easily strike those with a weakened or compromised immune system.

We already know that a limb effected by lymphedema is immunio-compromised. THere is also evidence indicating that if you have lymphedema, primary or secondary, your entire lymphatic system may not be up to par.

Since the lymph system is such an integral part of the immune system, it would make sense that perhaps we may be more prone to these types of opportunistic infections (viral and bacterial).

The greatest danger for those of us with lymphedema is the risk of a secondary infection. Therefore, all due care must absolutely be underaken to insurd the blisters do not pop and become infected.

Another important point along these lines is the use of steroids on a person with lymphedema. When I had a terrible outbreak in 1986, my ID doctor did not and would not give me steroidss for the shingles.

The reason is the effect steroids have on your immune system (not to mention to possible edema).

I was able to use other medication, topical ointments and pain meds.

Here's some basic info on shingles:

NINDS Shingles Information Page

Synonym(s): Postherpetic Neuralgia, Herpes Zoster

What is Shingles?

Shingles (herpes zoster) is an outbreak of rash or blisters on the skin that is caused by the same virus that causes chickenpox — the varicella-zoster virus. The first sign of shingles is often burning or tingling pain, or sometimes numbness or itch, in one particular location on only one side of the body. After several days or a week, a rash of fluid-filled blisters, similar to chickenpox, appears in one area on one side of the body. Shingles pain can be mild or intense. Some people have mostly itching; some feel pain from the gentlest touch or breeze. The most common location for shingles is a band, called a dermatome, spanning one side of the trunk around the waistline. Anyone who has had chickenpox is at risk for shingles. Scientists think that in the original battle with the varicella-zoster virus, some of the virus particles leave the skin blisters and move into the nervous system. When the varicella-zoster virus reactivates, the virus moves back down the long nerve fibers that extend from the sensory cell bodies to the skin. The viruses multiply, the tell-tale rash erupts, and the person now has shingles.

Is there any treatment?

The severity and duration of an attack of shingles can be significantly reduced by immediate treatment with antiviral drugs, which include acyclovir, valcyclovir, or famcyclovir. Antiviral drugs may also help stave off the painful after-effects of shingles known as postherpetic neuralgia. Other treatments for postherpetic neuralgia include steroids, antidepressants, anticonvulsants, and topical agents.

In 2006, the Food and Drug Administration approved a VZV vaccine (Zostavax) for use in people 60 and older who have had chickenpox. When the vaccine becomes more widely available, many older adults will for the first time have a means of preventing shingles. Researchers found that giving older adults the vaccine reduced the expected number of later cases of shingles by half. And in people who still got the disease despite immunization, the severity and complications of shingles were dramatically reduced. The shingles vaccine is only a preventive therapy and is not a treatment for those who already have shingles or postherpetic neuralgia.

What is the prognosis?

For most healthy people, the lesions heal, the pain subsides within 3 to 5 weeks, and the blisters leave no scars. However, shingles is a serious threat in immunosuppressed individuals — for example, those with HIV infection or who are receiving cancer treatments that can weaken their immune systems. People who receive organ transplants are also vulnerable to shingles because they are given drugs that suppress the immune system.

A person with a shingles rash can pass the virus to someone, usually a child, who has never had chickenpox, but the child will develop chickenpox, not shingles. A person with chickenpox cannot communicate shingles to someone else. Shingles comes from the virus hiding inside the person's body, not from an outside source.

What research is being done?

The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct shingles research in laboratories at the NIH and also support additional research through grants to major medical institutions across the country. Current research is aimed at finding new methods for treating shingles and its complications.

Select this link to view a list of studies currently seeking patients.

Organizations

American Chronic Pain Association (ACPA)
P.O. Box 850
Rocklin, CA 95677-0850
ACPA@pacbell.net
http://www.theacpa.org
Tel: 916-632-0922 800-533-3231
Fax: 916-632-3208

VZV Research Foundation [For Research on Varicella Zoster]
24 East 64th Street
5th Floor
New York, NY 10021
vzv@vzvfoundation.org
http://www.vzvfoundation.org
Tel: 212-371-7280
Fax: 212-838-0380

National Foundation for the Treatment of Pain
P.O. Box 70045
Houston, TX 77270
NFTPain@cwo.com
http://www.paincare.org
Tel: 713-862-9332
Fax: 713-862-9346

http://www.ninds.nih.gov/disorders/shin ... ingles.htm

...............

Shingles

Introduction

Shingles — also known as herpes zoster — is a viral infection that causes a painful rash.

Shingles is caused by the varicella-zoster virus, the same virus that causes chickenpox. After you've had chickenpox, the virus lies dormant in your nerves. Years later, the virus may reactivate as shingles.

Although painful, typically shingles isn't a serious condition. Sometimes, however, the rash can lead to a debilitating complication called postherpetic neuralgia. This condition causes the skin to remain painful and sensitive to touch for months or even years after the rash clears up.

Early treatment can help shorten a shingles infection and reduce the risk of complications.

Signs and Symptoms

The signs and symptoms of shingles may include:

Pain, burning, tingling, itching, numbness or extreme sensitivity in a certain part of the body
A red rash with fluid-filled blisters that begins a few days after the pain
Fever
Headache
Chills
Upset stomach
Typically, the shingles rash occurs on only one side of the body. It often appears as a band of blisters that wraps from the middle of your back around one side of your chest to your breastbone, following the path of the nerve where the virus had been dormant.

Sometimes, the shingles rash occurs around one eye or on one side of the neck or face.

Although the shingles rash may resemble chickenpox, the virus typically causes more pain and less itching the second time around.

Causes

Shingles is a second eruption of the varicella-zoster virus — the same virus that causes chickenpox.

Varicella-zoster is part of a group of viruses called herpes viruses, which includes the viruses that cause cold sores and genital herpes. Many of these viruses can lie hidden in your nervous system after an initial infection and remain dormant for years before causing another infection.

Anyone who's had chickenpox may develop shingles. If your immune system doesn't destroy the entire virus during the initial infection, the remaining virus can enter your nervous system and lie hidden for years. Eventually, it may reactivate and travel along nerve pathways to your skin — producing shingles.

The reason for the encore is unclear. Shingles is more common in older adults and those who have weak immune systems.

Risk Factors

About one in 10 healthy adults who've had chickenpox eventually develop shingles, usually after age 50. Most people develop shingles only once, but recurrences in other areas are possible.

Shingles isn't contagious. However, the varicella-zoster virus can cause chickenpox in anyone who hasn't had chickenpox before. The infection can be serious for certain groups of people with immune system deficiencies.

Until the shingles blisters scab over, avoid physical contact with:

Anyone who's never had chickenpox
Anyone who has a weak immune system
Newborns
Pregnant women (A chickenpox infection can be dangerous for a developing baby.)

When to seek medical advice

Consult your doctor as soon as you notice signs or symptoms of shingles. Prompt treatment can help shorten the infection and reduce the risk of complications.

Treatment is especially important when a rash develops near your eyes. An untreated rash in this area could lead to an infection of your cornea, which may cause temporary or permanent blindness.

Complications

For about one in five people who develop shingles, the pain continues in the same spot long after the blisters have cleared. This condition is known as postherpetic neuralgia.

When you have postherpetic neuralgia, damaged nerve fibers send confused and exaggerated messages of pain from your skin to your brain. This leaves the affected area of skin sensitive to even the slightest touch. For some people, the brush of clothing or a breeze can be excruciatingly painful.

Pain medication, antidepressants or anticonvulsant medications may help provide relief until the pain subsides.

Shingles can also lead to other complications, including inflammation of the brain (encephalitis) and other neurological problems. If shingles occurs on your face, it can cause hearing problems and temporary or permanent blindness. Loss of facial movement (paralysis) is possible as well. If blisters aren't properly treated, bacterial skin infections are another potential problem.

Treatment

Although an episode of shingles usually heals on its own within a few weeks, prompt treatment can ease pain, speed healing and reduce the risk of complications. Complications are more likely for people who have weak immune systems and people older than age 65.

Doctors typically prescribe oral antiviral medications such as acyclovir (Zovirax), valacyclovir (Valtrex) or famciclovir (Famvir) to treat shingles — preferably beginning within 48 to 72 hours of the first sign of the shingles rash. Sometimes, antiviral medications are combined with corticosteroids to reduce swelling and pain.

If the pain is severe — particularly if you develop postherpetic neuralgia — your doctor may prescribe painkillers. Sometimes tricyclic antidepressants or certain anticonvulsants are helpful. A topical ointment called capsaicin (Zostrix, Zostrix-HP) or a skin patch that contains the pain-relieving medication lidocaine may be soothing as well.

Prevention

The varicella virus vaccine (Varivax) — approved by the Food and Drug Administration in 1995 — has become a routine childhood immunization, given between ages 12 months and 18 months. The vaccine is also recommended for older kids and adults who've never had chickenpox.

The varicella virus vaccine prevents chickenpox for most people. If chickenpox does develop after vaccination, it's typically less severe.

The Food and Drug Administration (FDA) has also approved a vaccine (Zostavax) to help prevent shingles in adults age 60 and older. In one study involving thousands of participants, the shingles vaccine reduced the overall risk of shingles by about 50 percent for adults age 60 and older. For adults ages 60 to 69, the vaccine reduced the risk of shingles by 64 percent.

The shingles vaccine is given as a single injection, preferably in the upper arm. The most common side effects are redness, pain and swelling at the injection site, itching and headache.

Self-care

If you develop shingles, take good care of yourself:

Keep the affected area clean.
Apply cool, wet compresses to relieve pain.
Soak in a tub of lukewarm water or use calamine lotion to relieve itching and discomfort.
Take an over-the-counter pain reliever or anti-inflammatory drug, such as ibuprofen (Advil, Motrin, others).
Get plenty of rest.

http://www.mayoclinic.com/health/shingl ... DSECTION=1

...............

Shingles, an Unwelcome Encore

By Evelyn Zamula

In Italy, shingles also is called St. Anthony's fire, a fitting name for a disease that has bedeviled saints and sinners throughout the ages. Caused by the same varicella-zoster virus that causes chickenpox, shingles (also called herpes zoster) most commonly occurs in older people. Treatment was once limited to wet compresses and aspirin. Today's treatments provide a variety of ways to shorten the duration of a shingles outbreak and to control the associated pain. Sometimes, however, shingles leads to a chronic painful condition called post-herpetic neuralgia (PHN) that can be difficult to treat.

Initial Symptoms

After an attack of chickenpox, the varicella-zoster virus retreats to nerve cells in the body, where it may lie dormant for decades. But under certain conditions, usually related to aging or disease, the virus can reactivate and begin to reproduce. Once activated, the virus travels along the path of a nerve to the skin's surface, where it causes shingles.

Shingles' symptoms may be vague and nonspecific at first. People with shingles may experience numbness, tingling, itching, or pain before the classic rash appears. In the pre-eruption stage, diagnosis may be difficult, and the pain can be so severe that it may be mistaken for pleurisy, kidney stones, gallstones, appendicitis, or even a heart attack, depending on the location of the affected nerve.

The Outbreak

Pain may come first, but when the migrating virus finally reaches the skin--usually the second to the fifth day after the first symptoms--the rash tells all. The virus infects the skin cells and creates a painful, red rash that resembles chickenpox.

Doctors can distinguish shingles from chickenpox (or dermatitis or poison ivy) by the way the spots are distributed. Since shingles occurs in an area of the skin that is supplied by sensory fibers of a single nerve--called a dermatome--the rash usually appears in a well-defined band on one side of the body, typically the torso; or on one side of the face, around the nose and eyes. (Shingles' peculiar name derives from the Latin cingulum, which means girdle or belt.) If a diagnosis is in doubt, lab tests can confirm the presence of the virus.

The rash usually begins as clusters of small bumps that soon develop into fluid-filled blisters (vesicles). In turn, the blisters fill with pus (pustules), break open, and form crusty scabs. In about four or five weeks, the disease runs its course, the scabs drop off, the skin heals, and the pain fades. Most healthy individuals make an uneventful, if not particularly pleasant, recovery.

Not everyone sails through without incident, however. Although it's difficult to resist scratching the itchy rash, it's better to keep hands off, as the damaged skin may develop a bacterial infection requiring antibiotic treatment. After such an infection, the skin may be left with significant scarring, some of it serious enough to require plastic surgery.

Another complication called the Ramsay Hunt syndrome occurs when the varicella-zoster virus spreads to the facial nerve, causing intense ear pain. The rash can appear on the outer ear, inside the ear canal, on the soft palate (part of the roof of the mouth), around the mouth and on the face, neck and scalp. The hearing loss, vertigo and facial paralysis that may result are usually, but not always, temporary.

Occasionally, the rash will appear as a single spot or cluster of spots on the tip of the nose, called Hutchinson's sign. This is not good news. It means that the ophthalmic nerve is probably involved and the eye may become affected, possibly causing temporary or permanent blindness.

"My husband was undergoing chemotherapy treatment for prostate cancer," says Julia Hershfield, of Kensington, Md., "when he developed shingles in his right eye. The pain was so bad, that he lost all will to live. Shingles finished him." In people whose immune systems are extremely weakened, the shingles virus can also spread to the internal organs and affect the lungs, central nervous system and the brain, sometimes causing death.

Chickenpox Redux

Like other members of the herpes family (such as the herpes simplex viruses that cause cold sores and genital herpes), the varicella-zoster virus that causes chickenpox never completely leaves the body. Most people don't get chickenpox a second time. However, anyone who has had chickenpox has the potential to develop shingles, because after recovery from chickenpox, the virus settles in the nerve roots.

Researchers are not sure exactly what triggers the virus to spontaneously start reproducing in nerve cells later in life and reappear as shingles. However, they do know the virus may reactivate when the immune system is weak.

Certain factors can cause the immune system to let down its guard. Age is one of them. Immunity declines with aging, so susceptibility to disease increases. The incidence of shingles and of resulting PHN rises with increasing age. More than 50 percent of cases occur in people over 60. Older people may also lack exposure to children with chickenpox, thereby losing an opportunity to boost immunity and prevent virus reactivation. Although most people have only one attack of shingles, about 4 percent will have further attacks.

People who have had chickenpox cannot "catch" shingles from someone who has it. However, people who've never had chickenpox can be infected with chickenpox if exposed to someone with an active case of shingles. The rash sheds the varicella-zoster virus and can be contagious. A caregiver or other person who lacks immunity developed from a prior case of chickenpox or the vaccine must avoid coming into contact with the rash or contaminated materials.

Also at risk for shingles are people with leukemia, lymphoma, or Hodgkin's disease, and those whose immune systems have been weakened because they are HIV-positive, or have undergone chemotherapy, radiation, transplant surgery with immunosuppression, or treatment with corticosteroids. Moreover, about 5 percent of people with shingles are found to have an underlying cancer, about twice the number of people in the population expected to have undiagnosed cancer.

It pays to be vigilant when unexplained symptoms occur. "New development of a rash or pain, especially when it occurs on only one side of the chest or face, should prompt a visit to the health-care provider," says Therese A. Cvetkovich, M.D., a medical officer in the Food and Drug Administration's Center for Drug Evaluation and Research (CDER).

Controlling the Outbreak

Although viral diseases can't be cured, doctors can prescribe oral antiviral medications, such as Zovirax (acyclovir), Famvir (famciclovir) and Valtrex (valacyclovir), that help control the infection by hindering reproduction of the virus in the nerve cells. "Antiviral therapy may shorten the course of an episode of shingles," says Cvetkovich. "However, therapy must be started as early as possible after symptoms develop--within 48 hours--in order to have an effect."

To relieve pain, the doctor may recommend over-the-counter analgesics (pain-relieving drugs), such as ibuprofen and naproxen, or prescription drugs, such as indomethacin, all members of a class of medications known as nonsteroidal anti-inflammatory drugs. Acetaminophen is also commonly used to relieve the pain. If pain is severe, doctors may add stronger analgesics, such as codeine or oxycodone.

When the Pain Persists

In some patients, the misery continues long after the rash has healed. Many of the 1 million people who develop shingles each year experience a complication called post-herpetic neuralgia (PHN). This term refers to pain that is present in the affected area for months, or even years, afterward. Although the acute pain of shingles and the chronic pain of PHN (called neuropathic pain) both originate in the nerve cells, their duration and the reaction to treatment is different.

Pain that occurs with the initial outbreak responds to treatment and is limited in duration. In contrast, PHN lasts longer, is difficult to treat and can be incapacitating. Furthermore, for unknown reasons, older people suffer more from this debilitating pain than younger people. In many individuals, the skin is so sensitive that clothing or even a passing breeze cannot be tolerated on the affected area. Described by PHN sufferers as agonizing, excruciating, and burning, the pain can result in an inability to perform daily tasks of living, and lead to loss of independence and, ultimately, depression and isolation.

"I would rather have ten babies than the pain I've endured for the past ten years," says 87-year-old Etta Watson Zukerman of Bethesda, Md., who has lost partial use of her right arm and hand due to nerve damage from PHN. "Nothing my doctor prescribed helped. I even went to a sports medicine specialist who recommended exercises. They didn't help either." Many PHN sufferers receive no relief at all, no matter what medications or therapies they use. And what works for one doesn't necessarily work for another.

Treating the Pain

Doctors use other methods to alleviate pain with varying degrees of success. "One of the relatively new medications that I'm enthusiastic about is the Lidoderm patch," says Veronica Mitchell, M.D., director of the pain management center and inpatient pain service at Georgetown University Hospital, Washington, D.C. "It's the transdermal form of lidocaine and it's been studied in the PHN population with very good results," adds Mitchell. "We prescribed the Lidoderm patch for a patient who had intolerable side effects with oral medications--and no relief--and she's had about a 50 percent-plus improvement in pain relief. It's one of my first-line therapies." The medication contained in this soft, pliable patch penetrates the skin, reaching the damaged nerves just under the skin without being absorbed significantly into the bloodstream. This means that the patch can be used for long periods of time without serious side effects.

Yet another method used to treat PHN is transcutaneous electrical nerve stimulation, or TENS. A device that generates low-level pulses of electrical current is applied to the skin's surface, causing tingling sensations and offering some people pain relief. One theory as to how TENS works is that the electrical current stimulates production of endorphins, the body's natural painkillers.

TENS is not for everyone. "TENS didn't help at all," says Einar Raysor of Rockville, Md. "I found there was a problem in fine-tuning the administration of the electrical current. Low doses of the electrical current didn't do anything for me. When the technician increased the current, it gave me a painful response. After this happened a couple of times, we dropped the treatment."

As a last resort, invasive procedures called nerve blocks may be used to provide temporary relief. These procedures usually entail the injection of a local anesthetic into the area of the affected nerves. "We have controversial results in the terms of the efficacy of nerve blocks," says Mitchell. "I do consider nerve blocks in treating PHN and I would perform them because there's some evidence that they work, but the real efficacy is to catch and treat the patient in the acute shingles phase. As PHN presents mostly in the elderly, and the older patient often is unable to tolerate some of the medications we use, I find nerve blocks useful in these cases."

Injection directly into the spine is another option for relief of pain that is not easily treated. A Japanese clinical study published in the New England Journal of Medicine found that an injection of the steroid methylprednisone combined with the anesthetic lidocaine reduced pain by more than 70 percent in one patient group compared with groups that received lidocaine alone or an inactive substance.

Prevention, Almost Perfect

Before the FDA approved the chickenpox vaccine in 1995, about 95 percent of the U.S. population developed chickenpox before age 18. Since then, more than 60 percent of American youngsters have been vaccinated against chickenpox.

"The vaccine is a live attenuated strain of the chickenpox virus," says Philip R. Krause, M.D., lead research investigator in the FDA's Center for Biologics Evaluation and Research. "However, it's a weaker form so it gives rise to a milder infection. But in the course of giving rise to this milder infection, it induces enough immunity to prevent people from getting the natural infection." It is estimated that the vaccine is between 75 and 85 percent effective in preventing chickenpox. "But the important thing," says Krause, "is that it is almost completely effective in preventing severe cases of chickenpox."

Now that we have a chickenpox vaccine, are shingles and PHN on their way out? Although the FDA hasn't evaluated the effects of the vaccine on shingles, Krause believes that "in the long term, if you can prevent enough people from getting the wild (natural) type of chickenpox, you're likely to see a beneficial effect on the incidence of shingles and post-herpetic neuralgia. But it may take several generations for this to happen."

Evelyn Zamula is a freelance writer in Potomac, Md.

People who have had chickenpox (varicella zoster) in their youth can develop shingles (herpes zoster) in later years. During an acute attack of the chickenpox virus, most of the viral organisms are destroyed, but some survive, travel up nerve fibers along the spine, and lodge in nerve cells where they may lie dormant for many years. A decrease in the body's resistance can cause the virus to reawaken decades later. It then travels back down the nerve fibers to the skin's surface.

The reawakened virus generally causes a vague burning sensation or tingling over an area of skin. A painful rash usually occurs two to five days after the first symptoms appear. A cluster of small bumps (1) turns into blisters (2) that resemble chickenpox lesions. The blisters fill with pus, break open (3), crust over (4), and finally disappear. This process takes four to five weeks.

A painful condition called post-herpetic neuralgia can sometimes occur. This condition is thought to be caused by damage to the nerves (5), and can last from weeks to years after the rash disappears.

Shingles Prevention Study
For many years, physicians could shorten the episodes of shingles, but they have had no means to prevent the disease, which affects up to one-half of all people who reach the age of 85. Now, this void in the medical armamentarium may change as a result of a major study of an experimental vaccine conducted by the Department of Veterans Affairs in collaboration with the National Institute of Allergy and Infectious Diseases (NIAID) and Merck & Co.

The study, whose outcome was announced in June, 2005, was launched in 1999 and included 38,546 participants 60 years of age or older. The volunteers' average age was 69, 7 percent were older than 80, and 40 percent were women. Half of the subjects were injected with a highly potent version of VZV, Merck's chickenpox vaccine for immunization of children, and half received a placebo.

By the end of the randomized, double-blind trial, 642 (3.3 percent) of the placebo recipients but only 315 (1.6 percent) of those treated with vaccine were diagnosed with shingles. The difference in the incidence of postherpetic neuralgia was even greater: the painful condition affected 80 study subjects on placebo, but only 27 of those who had been vaccinated.

"A preventive shingle vaccine would be an enormous boon for the health and quality of life of seniors," said Anthony S. Fauci, M.D., director of the NIAID. "We are extremely gratified that the public-private partnership has led to these exciting results, which have the potential to greatly benefit seniors in years to come."

--E.Z.

http://www.fda.gov/fdac/features/2001/301_pox.html

...........

Lymphedema People

http://www.lymphedemapeople.com

[patoco]

Zoster vaccine live

Pharmacotherapy. 2007 Jul

Kockler DR, McCarthy MW.
Drug Information Services, Virginia Commonwealth University Health System-Medical College of Virginia Hospitals, and the Virginia Commonwealth University School of Pharmacy, Charlottesville, Virginia 23298-0042, USA. dkockler@mcvh-vcu.edu

Keywords: herpes zoster vaccine, shingles, varicella-zoster virus vaccine, Zostavax.

Herpes zoster (shingles) is a neurocutaneous disease caused by the varicella-zoster virus and is associated with significant morbidity and long-term sequelae in older adults. Until recently, treatment options for these complications have been primarily targeted at disease state management and symptom relief. Zoster vaccine live is the first vaccine approved for the prevention of herpes zoster.

The vaccine was approved by the United States Food and Drug Administration for adults aged 60 years or older. Results of the Shingles Prevention Study demonstrated that in older individuals, administration of zoster vaccine live reduces the burden of illness associated with herpes zoster by 61.1%, the frequency of herpes zoster pain and discomfort by 51.3%, and the frequency of postherpetic neuralgia by 66.5%.

Overall, adverse events reported in clinical trials of zoster vaccine live were classified as mild. Events that occurred more frequently in zoster vaccine live recipients than in placebo recipients included injection site reactions, headache, respiratory infections, fever, flu syndrome, diarrhea, rhinitis, skin disorders, respiratory disorders, and asthenia.

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recently recommended universal vaccination for those 60 years of age and older, including those who have experienced previous episodes of shingles.

http://www.atypon-link.com/doi/abs/10.1 ... .27.7.1013

* * * * *

Zoster vaccine live (Oka/Merck).

Drugs Aging. 2006

Robinson DM, Perry CM.
Adis International Limited, Auckland, New Zealand. demail@adis.co.nz

A subcutaneously administered, live, high-titre (18,700-60,000 plaque-forming units per dose) varicella zoster virus (VZV) vaccine (zoster vaccine) of the Oka/Merck strain has been evaluated for the prevention of herpes zoster and the reduction of zoster-associated pain in adults aged > or =60 years. Zoster vaccine, when compared with placebo, reduced the burden of herpes zoster illness by 61%, the incidence of herpes zoster by 51% and the incidence of postherpetic neuralgia by 67% during more than 3 years of surveillance. The zoster vaccine caused an initial 1.7-fold rise in VZV antibody titre after 6 weeks that declined progressively over 3 years. Increases in gamma-interferon-secreting peripheral blood mononuclear cells were 2.2-fold greater with the zoster vaccine than with placebo 6 weeks after vaccination. Zoster vaccine was generally well tolerated.

The most frequently reported adverse reactions following vaccination were injection-site reactions; the only systemic adverse event with zoster vaccine that differed significantly in incidence from that with placebo was headache.

PMID: 16872235 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/sites/entre ... stractPlus

* * * * *

Varicella-zoster virus vaccine: a review of its use in the prevention of herpes zoster in older adults.

Drugs Today (Barc). 2006 Apr

Caple J.
Medical Information Department, Prous Science, Barcelona, Spain. journals@prous.com

Current strategies for managing herpes zoster show variable efficacy and do not prevent its appearance. Varicella-zoster virus vaccine, or "zoster vaccine" is a more potent form of the varicella-zoster virus vaccine currently approved for use in the prevention of varicella in children.

Zoster vaccine decreases the incidence of herpes zoster and burden of illness in adults aged 60 years and older and appears more efficacious in patients aged 60-69 than in those over 70 years.

Importantly, the incidence of postherpetic neuralgia is significantly reduced in patients who receive zoster vaccine, irrespective of age or not allowed. The duration of postherpetic neuralgia is also significantly reduced.

Zoster vaccine has a favorable safety profile; most treatment-related adverse events are related to the site of injection. This review summarizes the current data on the clinical efficacy and safety of zoster vaccine in adults aged 60 years and older. Copyright (c) 2006 Prous Science.

http://journals.prous.com/journals/serv ... fId=973589

* * * * *

Cost-effectiveness of a vaccine to prevent herpes zoster and postherpetic neuralgia in older adults.

Ann Intern Med. 2006

Hornberger J, Robertus K.
SPHERE Institute and Acumen LLC, Burlingame, California 94010, USA. jhornberger@acumen-llc.com

BACKGROUND: The Shingles Prevention Study showed that a varicella-zoster virus (VZV) vaccine administered to adults 60 years of age or older reduced the incidence of herpes zoster from 11.12 to 5.42 cases per 1000 person-years. Median follow-up was 3.1 years, and relative risk reduction was 51.3% (95% CI, 44.2% to 57.6%).

OBJECTIVE: To assess the extent to which clinical and cost variables influence the cost-effectiveness of VZV vaccination for preventing herpes zoster in immunocompetent older adults.

DESIGN: Decision theoretical model.

DATA SOURCES: English-language data published to March 2006 identified from MEDLINE on herpes zoster rates, vaccine effectiveness, quality of life, medical resource use, and unit costs. Target Population: Immunocompetent adults 60 years of age or older with a history of VZV infection. Time Horizon: Lifetime. Perspective: U.S. societal.

Interventions: Varicella-zoster virus vaccination versus no vaccination. Outcome Measures: Incremental quality-adjusted survival and cost per quality-adjusted life-year (QALY) gained. Results of Base-
Case Analysis: By reducing incidence and severity of herpes zoster, vaccination can increase quality-adjusted survival by 0.6 day compared with no vaccination. One scenario in which vaccination costs less than 100,000 dollars per QALY gained is when 1) the unit cost of vaccination is less than 200 dollars, 2) the age at vaccination is less than 70 years, and 3) the duration of vaccine efficacy is more than 30 years. Results of Sensitivity

Analysis: Vaccination would be more cost-effective in "younger" older adults (age 60 to 64 years) than in "older" older adults (age > or =80 years).

Longer life expectancy and a higher level of vaccine efficacy offset a lower risk for herpes zoster in the younger group. Other factors influencing cost-effectiveness include quality-of-life adjustments for acute zoster, unit cost of the vaccine, risk for herpes zoster, and duration of vaccine efficacy.

LIMITATIONS: The effectiveness of VZV vaccination remains uncertain beyond the median 3.1-year duration of follow-up in the Shingles Prevention Study.

CONCLUSIONS: Varicella-zoster virus vaccination to prevent herpes zoster in older adults would increase QALYs compared with no vaccination. Resolution of uncertainties about the average quality-of-life effects of acute zoster and the duration of vaccine efficacy is needed to better determine the cost-effectiveness of zoster vaccination in older adults.

http://www.annals.org/cgi/reprint/145/5/317

[patoco]

The Impact of Acute Herpes Zoster Pain and Discomfort on Functional Status and Quality of Life in Older Adults.

Clin J Pain. 2007 July/August

Chan IS, Choo P, Levin MJ, Johnson G, Williams HM, Oxman MN.
*Duke University †GRECC, Durham VA Medical Centers, Durham, NC ‡Merck Research Laboratories, West Point, PA §Harvard Vanguard Medical Associates, Chelmsford ∥Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA ¶University of Colorado Health Sciences Center, Denver, CO #VA Cooperative Studies Program Coordinating Center, West Haven, CT **University of California, San Diego and San Diego VA Medical Centers, La Jolla, CA.

OBJECTIVES: To describe the interference of herpes zoster (HZ) pain and discomfort with activities of daily living (ADLs) and health-related quality of life (HRQL) during the acute rash phase, and to quantify the relationship between acute HZ pain and discomfort and impaired ADLs and HRQL in older persons.

METHODS: Prospective, observational study of 160 HZ outpatients age >/=60 at 4 US study sites who completed the Zoster Brief Pain Inventory (ZBPI), Zoster Impact Questionnaire (ZIQ), McGill Pain Questionnaire, EuroQol, and SF-12 questionnaires on a predetermined schedule. Patients rated interference on a 0 to 10 scale for ADL items in the ZBPI and the ZIQ. Interference scores were averaged to create summary measures for the ZBPI items (ZBPI ADLI) and ZIQ items (ZIQ ADLI). A composite pain score was used in mixed-effects models analyses of the association between pain and discomfort and ADLI and HRQL measures during the first 35 days after HZ rash onset.

RESULTS: HZ pain interfered with all ADLs but interference was greatest for enjoyment of life, sleep, general activity, leisure activities, getting out of the house, and shopping. For every 1.0 point increase in pain and discomfort intensity, there was a 0.69 and 0.53 point increase in ZBPI and ZIQ interference, respectively, and a 2.81 point, 1.57 point, and 1.95 point decrease in EuroQol, SF-12 physical, and SF-12 mental scales, respectively.

DISCUSSION: Acute zoster pain and discomfort has a significant negative impact on functional status and HRQL in older adults. The magnitude of interference increases with increasing pain and discomfort intensity.

http://www.clinicalpain.com/pt/re/clnjp ... 29!8091!-1

[patoco]

Why do so many clinicians believe that recurrent zoster is common?

Why do so many clinicians believe that recurrent zoster is common?
Andy J Chien MD PhD, John E Olerud MD
Dermatology Online Journal 13 (2): 2

The University of Washington Department of Medicine, Division of Dermatology, Seattle WA, 98195. andchien@u.washington.edu

It is my clinical experience that recurrent zoster is not so rare. Such is the unanimous opinion of more than a half dozen peer reviewers and journal editors who have summarily dismissed our attempts in the past 2 years to address the issue of recurrent zoster in immunocompetent individuals. Recurrent zoster, they contend, is not reported in the literature because it is a commonplace occurrence. Is that really the case?

Articles dating back to 1900 purport cases of recurrent zoster, but most of these reports predated routine laboratory testing for varicella zoster virus (VZV), which was first cultured from herpes zoster lesions by Weller and Stoddard in 1952. In 1965 Hope-Simpson published a review of 192 cases of herpes zoster seen in a 16-year period in Cirencester England, classifying 8 of 192 as second-attacks and 1 of 192 as a third attack [1]. However, reports as early as 1950 noted that HSV could clinically imitate herpes zoster [2]. Ironically, there are actually more laboratory-confirmed cases of misdiagnosed recurrent zoster in the literature than there are of actual recurrent zoster in immunocompetent patients. Heskel and Hanifin described three patients initially diagnosed with recurrent herpes zoster, but all with HSV by culture, again raising the question as to whether earlier cases of recurrent zoster represent instead misdiagnosed cases of HSV [3].

In patients with HIV infection, several reports have documented chronic infection with VZV, manifesting both as disseminated varicella as well as persistent or recurrent zosteriform lesions. However, even the absence of HIV, the clinicians with whom we've discussed this issue are nearly universal in their view that recurrent zoster is not uncommon. A recent study on the prevention of zoster with VZV vaccination enrolled 38,546 immunocompetent patients, of whom 1308 were diagnosed with herpes zoster, and 3 were subsequently diagnosed with recurrent zoster [4]. This large study, even with the assumption that these three cases were true recurrences despite the absence of laboratory confirmation, suggests that clinicians would need to see a very large number of zoster cases before encountering a true recurrence.

We saw a 67 year-old female patient with a 4-year history of actinic reticuloid treated intermittently using varying doses of oral prednisone over that time period. Over the next 5 months, she developed three separate episodes of a vesicular eruption along the L3-L4 dermatome that resolved with valacyclovir therapy. Upon her third visit, laboratory testing confirmed VZV by a positive fluorescent antibody (FA) test and a positive viral culture, making her a true case of recurrent zoster. Laboratory-confirmed cases of recurrent zoster in immunocompetent individuals are rare in the literature. In 2004 Nikkels and colleagues presented a 5-year-old male with two episodes of herpes zoster occurring fifteen months apart in separate dermatomes (S2-3, then C6), with both outbreaks confirmed by FA positivity for VZV [5]. To our knowledge, there are no other laboratory confirmed cases of cutaneous zoster recurrence in immunocompetent individuals, although there are rare cases reported in the ophthalmology literature without cutaneous findings.

Our patient was on prednisone, a well-recognized risk for getting herpes zoster, because VZV reactivation is related in part to the state of cell-mediated immunity. Despite the large number of patients on immunosuppressive medications like prednisone, there are no reports documenting increased risk of recurrent or persistent herpes zoster in this population like there is with the HIV population. While patients with hematologic malignancies exhibit higher rates of herpes zoster, increased rates of recurrent herpes zoster have not been reported in this population either.

From the standpoint of infective transmissibility, there are different implications for herpes zoster and HSV-mediated zosteriform simplex. With the exception of persons who have not had chickenpox or those who are severely immunosuppressed, exposure to a patient with herpes zoster poses no proven infectious risk. On the other hand, there is considerable literature regarding the non-venereal transmission of HSV, including well-described entities such as eczema herpeticum and herpes gladiatorum. Live HSV virus has been isolated from inanimate surfaces, common household objects, medical charts, and even in hot tubs from spa facilities [6]. Without clear distinction between true recurrent zoster and HSV-mediated zosteriform simplex, both patients and their future contacts may be inadequately educated regarding the precautions needed to prevent viral transmission.

A colleague in internal medicine spoke to us about a case of recurrent zoster in her clinic. This patient was seen by several different physicians who all concluded with the diagnosis of recurrent zoster. After seeing our review of the literature, she subsequently performed laboratory testing on this patient and confirmed the diagnosis of HSV-mediated zosteriform simplex. There are several other patients in their clinic who are also thought to have "recurrent zoster". We predict that laboratory testing of these patients will confirm what is already demonstrated by the evidence at hand: recurrent zoster in the immunocompetent is an extremely uncommon event.

References
1. Hope-Simpson RE. The nature of herpes zoster: a long-term study and a new hypothesis. Proc R Soc Med 1965; 58: 9-20.

2. Slavin HB and Ferguson Jr JJ. Zoster-like eruption caused by the virus of herpes simplex. Am J Med 1950; 8: 456-67.

3. Heskel NS and Hanifin JM. Recurrent zoster: an unproven entity? J Am Acad Dermatol. 1984; 10(3):486-90.

4. Oxman MN et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005; 352(22): 2271-84.

5. Nikkels AF, Nikkels-Tassoudji N and Pierard GE. Revisiting childhood herpes zoster. Pediatr Dermatol. 2004; 21(1): 18-23.

6. Nerurkar LS, West F, May M, Madden DL, Sever JL. Survival of herpes simplex virus in water specimens collected from hot tubs in spa facilities and on plastic surfaces. JAMA. 1983 Dec 9; 250(22):3081-3

© 2007 Dermatology Online Journal

http://dermatology.cdlib.org/132/commen ... chien.html

[patoco]

Natural history of pain following herpes zoster.

Pain. 2007 Mar

Thyregod HG, Rowbotham MC, Peters M, Possehn J, Berro M, Petersen KL.
UCSF Pain Clinical Research Center, Department of Neurology, University of California, San Francisco, CA 94115, USA.

Keywords: AHZ, Post herpetic neuralgia, Questionnaires, SFMPQ, MPI, Diagnostic criteria

In a longitudinal observational study of 94 patients (39 M:55 F, mean age 69) at elevated risk for developing post herpetic neuralgia (PHN), the natural history of pain during the first 6 months after herpes zoster (HZ) rash onset was determined. Pain severity and impact were rated using pain-VAS, SF-MPQ, and MPI. Applying a definition of PHN of average daily pain >0/100 on the pain VAS during the last 48 h, 30 subjects had PHN at 6 months.

These 30 subjects reported more pain and a higher SF-MPQ score (p<0.01) at study inclusion than the 64 subjects whose pain completely resolved by 6 months. At 6 months, mean daily pain in the PHN group was 11/100 (95% CI 5,16) and only nine of these subjects were still taking prescription medication for HZ pain.

The rate of recovery (pain severity over time) was the same in the PHN and no-pain groups. At study inclusion, the SF-MPQ and MPI scores in our PHN group were similar to historical controls with chronic severe PHN enrolled in clinical trials, but by 6 months the scores in our PHN subjects were significantly lower than historic controls. Only two subjects met the more stringent criteria for 'clinically meaningful' PHN at 6 months (> or = 30/100 on the pain VAS).

Defining PHN as average daily pain >0/100 at 6 months after rash onset appears to substantially overestimate the number of HZ patients negatively impacted by ongoing pain and disability.

http://www.painjournalonline.com/articl ... X/abstract

[patoco]

Management strategies for herpes zoster and postherpetic neuralgia

J Am Osteopath Assoc. 2007

Galluzzi KE.
Philadelphia College of Osteopathic Medicine, 4190 City Avenue, Philadelphia, PA 19131-1633, USA. katherineg@pcom.edu

Evidence-based strategies for the management of herpes zoster and postherpetic neuralgia (PHN) include the use of antiviral agents in acute zoster and specific analgesics in PHN. Antiviral agents are effective in reducing the severity and duration of acute herpes zoster when given within 72 hours of rash onset, but they do not prevent PHN. Anticonvulsants, tricyclic antidepressants, opioids, and topical treatment modalities such as lidocaine-containing patches and capsaicin cream offer moderate pain relief to some patients with PHN, but they may be associated with adverse events that limit their use. Therefore, prevention of herpes zoster and PHN with prophylactic vaccination using the zoster virus vaccine is an effective strategy to reduce the morbidity of these conditions. Treatment modalities are available, however, that may shorten the duration of acute herpes zoster and alleviate the pain of PHN.

http://www.jaoa.org/cgi/pmidlookup?view ... d=17488885

* * * * *

Post-herpetic neuralgia in older adults: evidence-based approaches to clinical management.

Christo PJ, Hobelmann G, Maine DN.
Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA. pchristo@jhmi.edu

Many individuals across the globe have been exposed to the varicella-zoster virus (VZV) that causes chickenpox. After chickenpox has resolved, the virus remains latent in the dorsal root ganglia where it can re-emerge later in life as herpes zoster, otherwise known as shingles. Herpes zoster is a transient disease characterised by a dermatomal rash that is usually associated with significant pain. Post-herpetic neuralgia (PHN) is the term used for the condition that exists if the pain persists after the rash has resolved. Advanced age and compromised cell-mediated immunity are significant risk factors for reactivation of herpes zoster and the subsequent development of PHN. Though the pathophysiology of PHN is unclear, studies suggest peripheral and central demyelination as well as neuronal destruction are involved. Both the vaccine against VZV (Varivax) and the newly released vaccine against herpes zoster (Zostavax) may lead to substantial reductions in morbidity from herpes zoster and PHN. In addition, current evidence suggests that multiple medications are effective in reducing the pain associated with PHN. These include tricyclic antidepressants, antiepileptics, opioids, NMDA receptor antagonists as well as topical lidocaine (lignocaine) and capsaicin. Reasonable evidence supports the use of intrathecal corticosteroids, but the potential for neurological sequelae should prompt caution with their application. Epidural corticosteroids have not been shown to provide effective analgesia for PHN. Sympathetic blockade may assist in treating the pain of herpes zoster or PHN. For intractable PHN pain, practitioners have performed delicate surgeries and attempted novel therapies. Although such therapies may help reduce pain, they have been associated with disappointing results, with up to 50% of patients failing to receive acceptable pain relief. Hence, it is likely that the most effective future treatment for this disease will focus on prevention of VZV infection and immunisation against herpes zoster infection with a novel vaccine.

PMID: 17233544 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/sites/entre ... stractPlus