I. Standardized treatment of herpes zoster
1. Definition of herpes zoster
Herpes zoster is an acute viral infection caused by varicella zoster virus latent in the human body, characterized by clusters of herpes zoster along the unilateral peripheral nerve distribution, often accompanied by significant neuralgia.
2, the main sites and proportion of herpes zoster occurrence
The main sites of herpes zoster are, in order of prevalence, the chest (intercostal nerve): more than 50%; the neck (cervical nerve): 10-20%; the skull (trigeminal nerve): 10-20%; the lumbosacral region (lumbosacral nerve innervation area): 2-8%; others: <2%.
3. Epidemiological characteristics of herpes zoster
(1) Incidence: Studies in the UK, Italy and Germany have shown that the incidence of herpes zoster exceeds 14.2 per 1,000 in the age group above 50 years. The annual incidence of herpes zoster in immunocompromised populations (HIV patients, cancer patients, and patients receiving immunosuppressive therapy) ranges from 14.5 per 1000 to 53.6 per 1000.
(2) Disease recurrence rate: When the body is stimulated in some way leading to a decrease in the body’s resistance, the latent virus is activated and travels down the sensory nerve axon to reach the skin in the area innervated by that nerve to replicate and produce blisters, while inflammation and necrosis occur in the affected nerve, producing neuralgia, and a longer-lasting immunity is obtained after healing, with a very low recurrence rate, which usually does not recur.
(3) Age and gender: Age is the most important factor influencing the incidence of herpes zoster. The results of studies in the United States, United Kingdom, and France have shown that women are more likely to develop herpes zoster, and the mechanism is not clear.
(4) Stress: Stress affects a range of neuroendocrine functions in the body, which interferes with cellular immune function and may cause an increased risk of developing herpes zoster in humans.
(5) Family aggregation: The trend of family aggregation of herpes zoster in the United States is significantly higher than that of other skin diseases, but a few scholars are against it, and further research is needed to prove it.
4. Clinical manifestations of herpes zoster before rash
The clinical manifestations of herpes zoster before rash emergence, i.e. the prodromal phase, include.
(1) mild malaise, low-grade fever, no chills, and decreased appetite.
(2) Self-perceived burning sensation or neuralgia in the affected skin, lasting 1-3 days.
5. Clinical manifestations of herpes zoster rash
The clinical manifestation of herpes zoster rash is that the local skin first appears as a flushed spot, and soon appears as a cluster of corn- to soy-sized papules that do not fuse. The lesions often occur on one side of the body and are arranged along one of the peripheral nerve distribution areas, generally not exceeding the midline, but sometimes slightly exceeding the midline, probably because some of the peripheral nerve fibers cross to the opposite side. Neuralgia is one of the characteristics of the disease and can appear before the onset or along with the lesions, often more intense in elderly patients, followed by rapid transformation into blisters, clarified by herpes, surrounded by a red halo, transparent herpes turns into pustules in about 3 days, partially broken, gradually dries up and crusts until it falls off after 7-10 days, leaving behind a temporary light redness or pigmentation.
6, the clinical manifestations of disseminated herpes zoster
The clinical manifestation of disseminated herpes zoster refers to the widespread varicella-like rash and invasion of organs such as lungs and brain by the virus spread through the bloodstream, which spreads throughout the body a few days (3-14 days) after the appearance of herpes zoster. It can be combined with serious complications such as pneumonia and meningoencephalitis, and the death rate is high, so it is a dangerous disease for herpes zoster.
7. Anti-viral treatment drugs for herpes zoster
Acyclovir, valacyclovir and famciclovir are currently the antiviral drugs of choice for the treatment of shingles.
8.Medication for herpes zoster neuralgia
(1) Analgesic drug therapy
(2) neurotrophic drug therapy
(3) Glucocorticoids
(4) When there is moderate or severe neuralgia in herpes zoster, consider the combination of antiepileptic drugs and opioid analgesics. When the effect of drug treatment is not good, nerve block therapy should be performed as soon as possible.
9.Nerve block for herpes zoster neuralgia
Nerve block can reduce the ectopic electrical activity of primary afferent receptors, block the vicious cycle of pain, block sympathetic nerves, improve local microcirculation, improve the nutrition of damaged nerves, reduce the inflammatory response, relieve the damage to ganglia and nerve fibers, and achieve the purpose of reducing and eliminating neuralgia. Intercostal nerve block, paravertebral spinal nerve block or stellate ganglion block or epidural block can be used according to the site of neuralgia. This method has the advantages of rapidly relieving the patient’s pain, shortening the course of the disease and reducing the incidence of post-herpetic neuralgia in patients with herpes zoster.
10. Local treatment of herpes zoster
When suffering from herpes zoster, attention must be paid to the prevention or early treatment of secondary bacterial infections. The first step is to keep the skin clean and change underwear regularly. Topical medication: dry and anti-inflammatory. Early physical therapy such as linear polarized light near infrared, ultraviolet light and helium-neon laser local irradiation can relieve pain and promote the drying and crusting of blisters.
Standardized treatment of herpes zoster postherpetic neuralgia
1.Definition of postherpetic neuralgia
Postherpetic neuralgia refers to a disease in which neuralgia persists after the herpes zoster rash has subsided, and the pain often lasts for more than one month. It is an intractable and intractable neuropathic pain, and is the most common complication of herpes zoster, manifesting as burning, electric shock-like, knife-like and needle-like pain in the lesion area, which seriously affects the patient’s quality of life and physical and mental health. It is important to treat post-herpetic neuralgia in a timely manner, as the longer the course of the disease, the more difficult it is to treat, especially if the course of the disease is more than 3 years or more, the difficulty of clinical treatment increases significantly.
2. Clinical manifestations of postherpetic neuralgia
Acute herpes zoster clinical cure 1 month after the affected area still exists persistent or episodic severe pain, the affected area within the visible obvious pigmentation changes; the corresponding innervation area clear history of herpes zoster, the affected area has obvious sensory and tactile abnormalities, pain increased by touching clothes or bed sheets; spontaneous cut-like or electric shock-like pain or tingling sensation or persistent burning pain is dominant. Some patients with postherpetic neuralgia are accompanied by intolerable itching.
3.The main risk factors for the occurrence of postherpetic neuralgia
(1) Age: the older you are, the greater the likelihood of developing postherpetic neuralgia.
(2) Gender: women are more likely to develop postherpetic neuralgia.
(3) The presence of antecedent pain before the appearance of herpes.
(4) intensity of acute herpes zoster pain: the more intense the pain, the greater the likelihood of postherpetic neuralgia
(5) Severity of lesions: the more blisters and the more extensive the lesions, the greater the likelihood of postherpetic neuralgia.
(6) failure to administer early, adequate and effective antiviral therapy
(7) Level of humoral and cellular immunity.
4.Pharmacological treatment of postherpetic neuralgia
Drug therapy is still the primary method of treatment for postherpetic neuralgia. It is necessary to select drugs according to individual characteristics, monitor drug side effects and drug interactions, and adjust drugs and their doses according to patient response.
(1) Antidepressants
(2) Anticonvulsants
(3) Drugs to promote nerve damage repair
(4) Opioids
(5) N-methyl-D-aspartate receptor antagonists
(6) Local medication
5.Minimally invasive treatment of postherpetic neuralgia
(1) Epidural cavity self-control analgesic technique: this technique has the function of reducing the degree of stress reaction, decreasing the scope and degree of neurogenic inflammation and promoting the repair of nerve damage. The effect is better in patients with a disease duration of six months.
(2) Pulsed radiofrequency technology: the use of intermittent pulsed electrical stimulation of the nervous system to treat pain has the effect of adjusting or modulating the nerve action rather than destroying it. It does not further damage the nerve tissue while treating pain.
(3) Spinal cord stimulation: It is a method to implant electrodes into the epidural space of the corresponding spinal cord segment to give appropriate stimulation and block the conduction of pain signals, so as to achieve analgesia. Neurostimulation can relieve pain, increase activity and reduce the use of analgesic drugs. However, neurostimulation is not effective for all patients.
(4) Percutaneous peripheral nerve stimulation: This is a method in which electrodes are placed percutaneously in the painful area to stimulate the affected peripheral nerve areas, and the stimuli are transmitted back to the spinal cord after convergence through these peripheral nerves. Percutaneous peripheral nerve stimulation has been used to treat specific areas of damaged nerve pain, including occipital, iliac groin, supraorbital, and trigeminal neuralgia, with the advantages of simplicity, minimal invasiveness, low risk, and no drug side effects. It is especially useful for elderly patients with comorbidities and limited access to other treatments.
(5) Intrathecal drug infusion system: Intrathecal drug infusion system can continuously pump opioids into the subarachnoid space, where the drug diffuses and binds to opioid receptors in the posterior horn of the spinal cord and brain tissue, producing good analgesia without affecting sensory and motor functions and sympathetic reflexes.
Attachment: Herpes zoster clinical pathway
Herpes zoster clinical pathway standard inpatient procedure
(I) Applicable objects: The first diagnosis of herpes zoster (without complications) (ICD-10: B02.9)
(B) Diagnosis basis: According to the Clinical Diagnosis and Treatment Guide-Dermatology and Venereal Diseases Sub-volume (edited by the Chinese Medical Association, People’s Health Publishing House), Clinical Technical Practice Guidelines-Dermatology and Venereal Diseases Sub-volume (edited by the Chinese Medical Association, People’s Military Medical Publishing House)
1.The rash is unilateral.
2. The distribution along the peripheral nerves and arranged into bands and clusters of blisters.
3.It may be accompanied by neuralgia.
(C) the choice of treatment plan: according to the Clinical Treatment Guide-Dermatology and Venereal Diseases Branch (edited by the Chinese Medical Association, People’s Health Publishing House), the Clinical Technical Practice Specification-Dermatology and Venereal Diseases Branch (edited by the Chinese Medical Association, People’s Military Medical Publishing House)
1.Anti-viral agent.
2.Anti-pain: medication.
3.Physical therapy.
4.Neurotropics.
5.Glucocorticoid.
6.Immune enhancer.
(D) The standard hospitalization days are 7-14 days.
(E) Entry pathway criteria.
1.The first diagnosis must meet the ICD-10: B02.9 Herpes zoster (uncomplicated) disease code.
2. When the patient has other disease diagnoses at the same time, but does not require special treatment during hospitalization that does not affect the implementation of the clinical pathway process for the first diagnosis, he/she can enter the pathway.
(F) Admission day 1.
1.Required examination items.
(1) Routine blood, routine urine and routine stool.
(2) Liver and kidney function, electrolytes, blood glucose, lipids, immunoglobulins, infectious disease screening (hepatitis B, hepatitis C, AIDS, syphilis, etc.).
(3) X-ray chest film and electrocardiogram.
2. Items selected according to the patient’s condition.
(1) Tumor-related screening: tumor antigens and markers, choice of performing ultrasound, CT, MRI examination, barium meal or endoscopy of the digestive tract.
(2) Culture of pathogenic microorganisms in traumatic secretions and drug sensitivity test.
(vii) The choice of drugs and timing of treatment.
1, antiviral agents: acyclovir, etc., the duration of drug use is about 1 week.
2, analgesic drugs: non-steroidal anti-inflammatory drugs, tricyclic antidepressants, carbamazepine, tramadol, gabapentin, etc., the duration of medication depends on the condition.
3, neurotrophic drugs: methylcobalamin, adenosine cobalamin, vitamin B1, etc., the duration of medication depends on the condition.
4, glucocorticoids: prednisone, etc., the duration of medication depends on the condition, generally 3-10 days.
5.Immunomodulators: thymidine, gammaglobulin, etc., the duration of medication depends on the condition.
6.Local drugs: Furfuracic lotion, antiviral and antibacterial agents, topical pain relievers, etc., the duration of medication depends on the condition.
7.Antibiotics: If necessary, use them according to the “Guidelines for Clinical Application of Antibacterial Drugs” (Health Care [2004] No. 285), and adjust the medication according to the culture of pathogenic microorganisms on the trauma surface and the results of drug sensitivity in a timely manner.
8.Physical therapy: He-Ne laser or semiconductor laser, ultraviolet light, etc. can be used, and the treatment time depends on the condition.
9.Supportive treatment and treatment of complications.
(H) Post-admission review examination items: review blood routine, liver and kidney function, electrolytes, blood sugar, etc. according to the patient’s condition.
(ix) Discharge criteria
1.Rash healed: no blisters, rash or crusted trauma.
2.No complications that require hospitalization.
(J) Variation and cause analysis.
1.In case of severe neuralgia and ineffective conventional treatment, consultation with neurology or analgesia department should be requested to assist in treatment.
2. With other underlying diseases or complications, further diagnosis and treatment or referral to other corresponding departments is required, prolonging the hospital stay and increasing the hospitalization cost.