Herpes zoster, commonly known as tangles, is caused by infection with the varicella zoster virus. After initial infection in a non-immune host, the clinical presentation is chickenpox in childhood. The virus migrates to the dorsal root ganglion of the spinal nerve or brain ganglion during the early stages of infection, then remains dormant and does not cause clinical symptoms. In some individuals, the virus reactivates in the presence of decreased resistance, etc., and then migrates along the distribution of the nerve, producing the typical painful and cutaneous lesion known as herpes zoster. Patients with malignant tumors (especially lymphoma), or chronic diseases, as well as those undergoing immunotherapy (radiotherapy, chemotherapy, hormone therapy) are usually weaker and therefore more susceptible to acute herpes zoster than the healthy population. These patients all have lower cellular immune function, which explains why herpes zoster occurs more often in people over 60 years of age and is relatively uncommon in people under 20 years of age. The most frequent site of acute herpes zoster is the chest, followed by the face. Most patients with acute shingles have pain that appears 3 to 7 days earlier than the rash, which often leads to misdiagnosis. When a typical rash is present, the diagnosis is soon clear in most patients. Similar to chickenpox, the rash of herpes zoster appears as clusters of papules, which quickly turn into papules and then blisters. These blisters will eventually fuse and then crust over. The rash area can be extremely painful, and any activity or touch can worsen the pain (e.g., wearing clothes or a blanket). As these lesions heal, the crusts fall off leaving pink scars that gradually lighten in color and shrink. In most patients, the skin lesions heal and the sensory sensitivity and pain disappear. For some patients, however, the pain persists. This common sequela is called postherpetic neuralgia and is more prevalent in the elderly than in the general population. The degree of postherpetic neuralgia can range from mild self-limiting pain to severe, persistent burning pain; the pain can be exacerbated by light touch, activity, stress, and changes in temperature. This constant pain can be severe enough to overwhelm the patient and eventually lead to suicide. In order to prevent the initially benign disease from progressing to a catastrophic sequelae, doctors must treat acute herpes zoster with every possible treatment. At present, it appears that not enough attention is paid to the treatment of pain in the early stages of shingles, and there is always the idea, both by doctors and by the patients themselves, that the pain will disappear naturally after treating the herpes. However, the proportion of postherpetic neuralgia in elderly people is quite high. Therefore, treating patients with acute shingles involves two aspects: 1) immediate relief of acute pain as well as symptoms; and 2) prevention of postherpetic neuralgia. Most pain specialists believe that the earlier treatment is started, the less likely postherpetic neuralgia will occur. In addition, older people are at a higher risk of developing postherpetic neuralgia and should be treated earlier and more aggressively. 1. Nerve block (Nerve Block) By sympathetic nerve block, the symptoms of acute herpes zoster can be relieved and the occurrence of postherpetic neuralgia can also be prevented. Sympathetic nerve block should be performed aggressively and repeatedly until the patient is no longer in pain. When the pain recurs, the block should be performed again. If sympathetic blocks are not performed aggressively and quickly, patients may develop postherpetic neuralgia, especially in the elderly. 2. Opioid Analgesics Opioid analgesics are usually effective in relieving the severe pain of the acute phase of herpes zoster when sympathetic blocks are performed. Opioid analgesics are less effective for common neuroinflammatory pain. Strong and long-acting narcotic analgesics [e.g., oral morphine extended-release, methadone] administered at regular intervals rather than as needed, and carefully administered, can supplement sympathetic blockade for pain relief. Because most patients are older or have multiple systemic diseases, the possible side effects of strong narcotic analgesics (e.g., dizziness, confusion, and other conditions that can cause the patient to fall) should be closely monitored. Oral narcotic analgesics should be supplemented with daily dietary fiber, milk and magnesium-containing laxatives to prevent constipation. 3. Adjuvant Analgesics The anticonvulsant gabapentin is the first line of treatment for acute herpes zoster neuritis pain of the trigeminal nerve. Studies suggest that gabapentin may also be helpful in the prevention of postherpetic neuralgia. Gabapentin should be used early in the course of the disease; it can be used concurrently with nerve blocks, opioid analgesics, and other adjunctive analgesics (including antidepressants), but care should be taken to avoid central nervous system side effects. The starting dose of gabapentin is 300 mg at bedtime, then titrated in increasing doses of 300 mg as side effects allow until a total daily dose of 3600 mg is administered orally in multiple doses. Carbamazepine should be considered for patients with severe neuroinflammatory pain that is not responding to nerve blocks and gabapentin. If this drug is used, blood levels should be strictly monitored, especially in patients undergoing concurrent chemotherapy or radiation therapy. Phenytoin is also useful in reducing neuroinflammatory pain, but should not be used in patients with lymphoma; it can induce a pseudolymphoma-like state that is difficult to distinguish from true lymphoma. 4. Antidepressants Antidepressants are also a useful adjunct in the initial treatment of acute herpes zoster. These drugs often help to reduce severe sleep disturbances in the acute phase of the patient. Antidepressants can also be used to treat neuroinflammatory pain that is less effective with narcotic analgesics. After a few weeks of treatment, antidepressants can have a mood-regulating effect, which is needed in some patients. These patients need to be closely monitored for central nervous system side effects. In addition, these drugs can cause urinary retention and constipation and can easily be mistaken for herpes zoster spinal cord infection. 5. Antiviral Agents There are several antiviral agents, including famciclovir and acyclovir, that can shorten the course of acute herpes zoster or even prevent it from occurring. Antiviral agents may help to reduce the disease in immunosuppressed patients. These antiviral agents may be used in conjunction with the above therapies. It is also important to monitor the occurrence of side effects. 6, Adjunctive Treatments (Adjunctive Treatments) Some patients on their acute herpes zoster lesion area given ice packs cold, can relieve symptoms. Heat therapy increases pain in most patients, which may be related to the acceleration of fine fiber conduction; however, heat therapy is occasionally effective for patients, so if cold therapy does not work, heat therapy can also be tried. Transcutaneous electrical nerve stimulation may also be effective in a small number of patients. These therapies have a good risk-benefit ratio and are an alternative for patients who are unable or unwilling to undergo sympathetic nerve blocks or who cannot tolerate pharmacologic therapy. Aluminum sulfate is a mild soak that can be applied to the skin to dry out crusted and exuding lesions, and is comfortable for most patients. Zinc oxide ointment can also be used as a skin protector, especially during the temperature-sensitive healing period. Dressings or large Band-Aids can also be used as pads to protect healing wounds from contact with clothing and linens.