From the Guidelines
Neuropathic pain in teenagers with varicella zoster (shingles) should be treated promptly with a combination of antiviral therapy and pain management, prioritizing gabapentin or pregabalin for moderate to severe pain, as recommended by the most recent guidelines 1. The treatment of neuropathic pain in teenagers with varicella zoster requires a multifaceted approach, considering the potential for long-term complications such as postherpetic neuralgia.
- Antiviral therapy is crucial in the management of varicella zoster, but the provided evidence does not specify the optimal antiviral regimen for teenagers 1.
- For pain management, the guidelines recommend starting with acetaminophen or NSAIDs for mild pain, and considering gabapentin or pregabalin for moderate to severe neuropathic pain 1.
- Gabapentin can be started at 300 mg once daily, gradually increasing to 300-600 mg three times daily as tolerated, while pregabalin can be started at 75 mg twice daily, increasing to 150-300 mg twice daily if needed 1.
- Tricyclic antidepressants like amitriptyline can be used at 10-25 mg at bedtime, increasing gradually if necessary, but with caution due to potential cardiac toxicity 1.
- Topical lidocaine 5% patches applied to the affected area for 12 hours daily may provide relief with minimal side effects 1. It is essential to monitor teenagers closely for medication side effects, as they may be more sensitive to these effects. Early treatment is crucial to prevent the development of postherpetic neuralgia, a persistent pain syndrome that can follow shingles infection.
From the Research
Teenager Neuropathic Pain in Varicella Zoster
- Varicella zoster virus can cause neuropathic pain, which is perceived before the development of rash and lasts even after its resolution 2.
- The pain during the first 30 days after onset of herpes zoster is known as acute herpetic neuralgia, and combination therapy with valacyclovir, methylprednisolone, and pregabalin has better efficacy compared to valacyclovir and pregabalin and valacyclovir alone in the management of acute herpes zoster neuralgia 2.
- Post-herpetic neuralgia (PHN) is a neuropathic pain syndrome that can cause significant suffering for years and is often refractory to treatment, and the best approach is to prevent the complication from occurring in the first place by preventing HZ with the HZ vaccine 3.
Treatment Options
- Gabapentin is effective in reducing neuropathic pain due to post-herpetic neuralgia when given at least three times per day, and a once-daily extended-release formulation of gabapentin has been developed to provide comparable drug exposure with an identical daily dose of the immediate-release formulation 4.
- Antiviral therapy, started early in the course of disease, can significantly reduce the risk and the duration of postherpetic neuralgia in elderly patients, and valaciclovir, famciclovir, and brivudine are comparably effective in the reduction of the incidence and/or prevention of zoster-associated pain and postherpetic neuralgia 5.
- A preclinical rodent model has been developed to explore the underlying mechanisms and treatments for VZV-induced pain, and the model has been used to investigate treatment modalities and aspects of pain signaling 6.
Mechanisms of Pain
- The mechanisms underlying protracted PHN are not understood, and the lack of an animal model of herpes zoster (reactivation) makes this issue more challenging 6.
- Dorsal root ganglia express a limited VZV gene subset, including the IE62 regulatory protein, and upregulate expression of markers suggesting a neuropathic pain state 6.
- The intensity of the therapy for pain should depend on the intensity of the pain that it is treating, and antiviral therapy in combination with adequate pain management should be given to all patients as soon as herpes zoster is diagnosed 5.