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Patients With Shingles Pain Benefit From Multimodal Treatment

NEW YORK (Jan 13, 2014)

Patients who suffer from chronic pain from shingles are finding relief thanks to pain specialists at NewYork-Presbyterian. Doctors employ a multimodal approach to treat the painful rash that is caused by the same virus that causes chickenpox.

After someone has had chicken pox, the virus usually lies dormant – hiding in nerve tissue – but it can reappear later in life in the form of shingles. Shingles is characterized by a painful rash and blisters and usually clears up within a few weeks. "Shingles is a complication of the chicken pox virus," said Maryam Jowza, M.D., an anesthesiologist and pain specialist.

Maryam Jowza, M.D.
Maryam Jowza, M.D.

However, sometimes patients are plagued by chronic pain, or postherpetic neuralgia, long after the shingles rash and blisters are gone. Postherpetic neuralgia can be described as a burning pain that lasts for months after the onset of the rash. It is especially prevalent in older patients with a compromised immune system from conditions such as cancer, an autoimmune disease or HIV. "Postherpetic neuralgia is pain that persists even after the rash has cleared up for months," said Dr. Jowza.

Early treatment has been shown to shorten the duration of a shingles infection and reduce the risk for complications such as postherpetic neuralgia. "The more pain patients have during the rash period is associated with more pain later. Early treatment for shingles reduces the likelihood of developing pain later on," said Dr. Jowza. "The location of the rash is also associated with development of pain or postherpetic neuralgia in that area," added Anis Dizdarevic, M.D., also an anesthesiologist and pain specialist. For example, if shingles occurs on the face, there is a higher likelihood that postherpetic neuralgia will occur there as opposed to other parts of the body.

Anis Dizdarevic, M.D.
Anis Dizdarevic, M.D.

Although there is no cure for postherpetic neuralgia, there are treatment options to alleviate symptoms. Doctors at NYP emphasize a multimodal approach to alleviate pain in the nerve fibers and skin. Treatments may include topical pain treatments that work by numbing the area and making it less sensitive to touch, medications such as antidepressants or anti-seizure medications, anti-inflammatory medications, interventions such as nerve blocks and steroid injections and psychological support. "We stress the multimodal therapy approach with chronic pain conditions such as shingles. We apply varying agents and advocate early treatment. Besides medications and injections, we offer psychological support in our clinic too. As you can imagine, this is a difficult condition that may significantly affect patient's mood, functionality and activities of daily living and can also be linked with depression," said Dr. Dizdarevic.

Dr. Jowza echoed this approach. "It depends on severity of pain but a multimodal approach works best. Typically I will treat patients with postherpetic neuralgia from shingles with a topical medication plus anti-seizure and antidepressant medications – the combined approach works better," she said.

"If you imagine in a seizure the nerves are firing very rapidly and erratically so the mechanism works very similarly to patients experiencing postherpetic neuralgia. Antidepressants for chronic pain from shingles do not work by improving mood but improving the way that your body handles pain signals," explained Dr. Jowza.

For more severe cases, there are several interventions that have shown to be very effective. "If there is involvement along the intercostal nerve in the thoracic region, various types of nerve blocks with or without anti-inflammatory steroid can be performed. Radiofrequency nerve ablation is another option. Spinal cord stimulation has been used in severe cases for patients who do not respond to conservative treatment. There are also reports of deep brain stimulation in severe cases of postherpetic neuralgia," said Dr. Dizdarevic.

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