Triamcinolone-Procaine in the Treatment of Zoster and Postzoster Neuralgia

Transcription

1 Triamcinolone-Procaine in the Treatment of Zoster and Postzoster Neuralgia ERVIN EPSTEIN, M.D., Oakland * Twenty-four patients with herpes zoster were treated with injections of 2 percent procaine hydrochloride containing 2 mg of triamcinolone per ml. The treatments were given subcutaneously under the cutaneous lesions and in areas of pain. The results were excellent in 22 patients. There was one failure-postzoster neuralgia in an 82- year-old woman. Of 12 patients with postherpetic neuralgia, eight had improvement of 70 to 90 percent and three had complete relief. There wvere no significant complications in either group. MANY INVESTIGATORS HAVE used many agents in the treatment of herpes zoster but the therapeutic efficacy of any of them is difficult to judge, for the disease is both self-limited and unpredictable. In 1957, Epstein and Allington' observed that no treatment advanced to that date was beneficial. None has been reported since that offers any greater hope. Now, a preliminary communication2 having stirred a great deal of interest, I am reporting good results in 22 of 24 patients with herpes zoster who were treated with triamcinolone in procaine. And the use of this preparation in 12 cases of postzoster neuralgia (which is less apt to subside spontaneously) has given brilliant, but not invariable, results. Technique of Treatment The treatment, which can be done in the office, consists of subcutaneous injections of a solution containing 200 mg of triamcinolone in the form of Aristocort 40 or Aristospan or Kena- From the Department of Dermatology, School of Medicine, University of California, San Francisco. Submitted July 9, Reprint requests to: th Street, Oakland, Ca (Dr. E. Epstein). log in 100 ml of 2 percent procaine hydrochloride. In some instances, saline solution or lidocaine (Xylocaine ) was substituted for the procaine hydrochloride. As the results with all three diluents and all three cortocosteroid preparations were comparable one to another, the triamcinolone is believed to be the important factor in this treatment. The indicated amount of this mixture is injected subcutaneously beneath the visible lesions and into the areas of pain, burning or itching. The strength of the solution is 2 mg of triamcinolone per ml. Up to 20 ml of the solution can be injected along the involved segment during a single session. More than this amount may cause vertigo. This dosage has been used on the face as well as on the trunk and extremities. Repeated daily injections may be given until adequate relief has been obtained. No attempt is made to inject the solution into a nerve, or to administer it perineurally. The reason for subcutaneous injection is to minimize the hazard of cutaneous atrophy which might add to the scarring caused by zoster in some patients. Moreover, care must be taken to avoid injecting the mixture into the adipose tis- 6 AUGUST 1971 * 1 15 * 2

2 sue lest painful panniculitis and abscess formation result. Maximum therapeutic benefits cannot be expected unless all of the involved areas are injected and it is important also that the dosage be adequate. For example, in one patient the initial dose was 15 ml (30 mg of triamcinolone) injected into the right side of the face. This was followed on successive days by injections into the same general area of 5 ml (10 mg), 3 ml (6 mg) and 5 ml (10 mg), a total of 28 ml (56 mg). Commonly 20 ml (40 mg) is injected daily into more extensive lesions on the trunk or limbs. Most patients respond well to smaller volumes of the mixture. The dose should be determined by the extent of involvement. Often when the patient notices little or no lessening of discomfort after the first treatment, the reason is that the entire area was not anesthetized. This is an indication for further therapy. If the remaining areas of maximum discomfort are injected, beneficial results may be expected. The patients are instructed to note the locations of greatest pain and burning, and these are injected selectively in subsequent treatments. Complications Pain. The injection tends to be painful despite the use of procaine or lidocaine. A 25 gauge needle is used routinely to minimize the discomfort of insertion but the medication itself causes moderate pain or burning or both. In general the sensation is no greater than that caused by the insertion of a local anesthetic into or under the skin before a surgical procedure. Hemorrhage. Bruising of the skin occurs commonly after the injection. It is more pronounced than that usually seen after similar subcutaneous injections of other medication, and it is noted most frequently in elderly patients and in those with postzoster neuralgia. This is merely a cosmetic handicap; it is not cause for discontinuing nor does it diminish the success of therapy. Abscess. A sterile abscess developed in one patient with supraorbital zoster over the forehead. The lesion was not particularly discomforting and it cleared quickly after incision and drainage. The zoster responded rapidly and completely to this approach. Scarring. No scarring was attributed to these injections, though the appraisal is a difficult one to make in the circumstances because the infection itself commonly causes cicatricial alterations. However, neither the physician nor the patient in any instance felt that the therapy had contributed to these permanent changes. There were no gross alterations in the scarring in patients with postzoster neuralgia even after many injections of this solution. Vertigo. This is common in elderly patients, especially in those receiving more than 15 or 20 ml of the medication in a single day. It is shortlived and does not contraindicate further injections. Failures. Postzoster neuralgia developed in one 82-year-old Negro woman with an acute zoster of the right side of the face. This did not respond to further therapy. In most reported series the incidence of postzoster neuralgia is about 10 percent. The incidence in the present group was 4.1 percent. Results Herpes Zoster. There were 24 patients with herpes zoster. One had persistent postzoster neuralgia. There were no other failures, although one patient who had good improvement after three injections did not return and the result is therefore uncertain. The results in the remaining 22 patients (91.6 percent) were considered to be excellent-complete clearing of pain, paresthesias and cutaneous manifestations. Scarring or absence of it was not considered in evaluating treatment. The series was not a particularly benign one. Several investigators3'4 have pointed out that postzoster neuralgia is more common in older patients, and in the present group of 22 patients with acute herpes zoster, 12 were more than 60 years of age and 17 were over 50. The usual ratio of men to women in large series is about 1:1, and although in the present one there were eight men and 16 women (1:2) this is not considered a significant factor. Seventy-five percent of the patients received four or fewer injections. The maximum was 13 doses-that in the patient who had persistent postzoster neuralgia. The average was 3.8 injections. The total volume of solution varied from 2 ml to 95 ml in the course of therapy, the average being 35.1 ml. Postzoster neuralgia. There were twelve pa- CALIFORNIA MEDICINE 7 The Western Journal of Medicine

3 TABLE 1.-Patients with Herpes Zoster Treated with Triamcinolone-Procaine Injections Injections Case Age Sex Location Duration No. Volume Results 1 74 F Left forehead "Days" Excellent 2 83 F Left 12 thoracic "Days" 2 8 Excellent 3 68 F Left S thoracic 1 week 4? Excellent 4 64 F Right side face 5 days 4 28 Excellent 5-15 F Right thigh 2 weeks 2 10 Excellent 6 71 F Left 12 thoracic 1 week 1 5 Excellent 7 72 li Left 10, 11, 12 thoracic 2 days 4 40 Excellent 8 63 F Left 10 thoracic 2 weeks 3 40 Excellent 9 48 M Right 12 thoracic 2 days 6 60 Excellent F Right 12 thoracic 2 weeks 6 70 Excellent F Left neck, arm 1 week 7 20 Excellent M Left forehead, nose, eyelids 4 days 4 33 Excellent F Left 12 thoracic 2 weeks 3 30 Improved, stopped treatinent F Left 12 thoracic 1 week 7 95 Excellent M Left scalp 1 week 2 2 Excellent F Left 1st lumbar 2 days 6 60 Excellent M Left ophthalmic 9 days 1 10 Excellent M Right neck, chest, shoulder, back 1 week 3 45 Excellent F Right cheek, lip 1 week Residual neuralgia F Left thigh, back 6 days 3 45 Excellent M Left neck, chest, shoulder 4 days 3 30 Excellent F Right eyelids, nose 2 weeks 1 5 Excellent F Right buttock 1 day 3 60 Excellent M Left axilla, back 6 days 2 20 Excellent TABLE 2.-Patients with Postzoster Neuralgia Treated with Triamcinolone-Procaine Injections Injections No. Age Sex Location Duration No. Volume Results 1 54 F Right 11 thoracic 3 months 2 10 Excellent 2 56 F Left hand, arn, back 14 months % well 3 47 F Left 5 thoracic 2 months % well 4 94 M Leg 3 months % well 5 65 F Left 6 thoracic 11 years % well 6 72 F Left 1,2, 3 lumbar 2 years 4? 95% well 7 18 M Left 4 thoracic 7 months 1 5 Excellent 8 74 M Left 12 thoracic 5% years Moderate improvement 9 67 M Left 6 thoracic 1 month Excellent F Left 12 thoracic 4 years % well F Left 12 thoracic 3% years % well F Left arm, hand 1 year % well tients with postzoster neuralgia of one month's to 11 years' duration, the average being 27.7 months. Four were men, eight women. Eight were more than 60 years of age and ten were over 50. The number of injections ranged from one to thirty, the average being 8.5 per patient. The volume of solution varied from 5 to 430 ml and the average was ml. Three of the 12 patients had complete abatement of symptoms (none of the three had had symptoms for longer than seven months) and eight had improvement that, by the patients' appraisal, was from 70 percent to more than 90 percent (mild paresthesias persisting). In one case, listed as a treatment failure, the dosage was grossly inadequate-four injections of 5 ml each. The 11 patients who were benefited felt that the course of therapy was well worth the cost, the inconvenience and the discomfort of the injections. Therefore, even in this very resistant disabling 8 AUGUST 1971 * 15 * 2

4 complication of zoster. this therapy could be considered to be successful, even if not invariably so. Discussion The evidence thus far is that the treatment herein described is a valuable one in the treatment of herpes zoster and postzoster neuralgia. The series is reasonably large-24 patients with acute zoster, 12 with postinfection neuritis. The immediate results in the dermatosis stage were excellent. The course of the disease was not shortened (an average of 19.5 days) but the low incidence of postzoster neuralgia plus prompt alleviation of discomfort indicates that the treatment is worthwhile. Eaglstein and coworkers4 found that systemic corticosteroids did not shorten the course of the infection but did relieve pain and decrease the likelihood of persistent pain. The injections used in the present series did the same but in a higher proportion of patients. In the Eaglstein series, 30 percent of the treated patients had postherpetic neuralgia (persistence of pain for more than eight weeks) and the pain was not alleviated until the patients had received at least two weeks of oral therapy with triamcinolone. The use of intralesional corticosteroid injections would seem to be a reasonable therapeutic measure in herpes zoster since probably neural and perineural inflammation are important in the development of symptoms. Sehgal and Gardner treated 12 patients with postzoster neuralgia by the local injection of hydrocortisone and procaine and reported results "good" in two and "fair" in five, and "poor" in three patients who were treated by local injection of procaine alone.5 These investigators also treated 12 patients with vitamin B12 (the results in all were poor), dilantin (14 out of 15 poor), cortisone by mouth (poor in all six patients followed), epidural injection of procaine and hydrocortisone acetate (eight poor results, two fair), and the intradural injection of methyl prednisolone acetate (18 poor, two fair). So, in their series, the best results were obtained by the local injection of a corticosteroid and a local anesthetic. Had triamcinolone been used, as in the series here reported, the results might have been better than those obtained with hydrocortisone. It is in the treatment of postzoster neuralgia that the method here described appears to be of greatest use. This condition is not self-limited. It seldom subsides spontaneously after it has been present for as long as a year. In seven of the group of 12 postzoster neuralgia patients herein reported, the pain had persisted for a year. Yet in nine of the group the benefit was rated at more than 70 percent and to 90 percent or more. Considering the therapeutic resistance of this manifestation, one must recognize the value of this procedure though acknowledging that it does not eradicate all the symptoms in all patients. It must be stressed that adequate dosage is essential although partial remission occurs promptly after a few injections in most cases. There has been some fear that corticosteroids might cause dissemination of the viral infection. However, there is now sufficient evidence to establish that this is very rare if it occurs at all. No side effects were encountered in this series. There is a certain amount of evidence that the procaine is not the crucial ingredient in this therapy. In one patient saline solution was substituted for the local anesthetic and the result was still good. In another, both triamcinolone and procaine were used separately without benefit. Procaine alone was ineffective in three instances reported by Sehgal and Gardner.5 However, it is recognized that local anesthetic agents alone have a dramatic result in some cases. Regardless of whether the beneficial effects are from the corticosteroid or the local anesthetic or the combination, it is of practical importance that the combination has proved successful in these patients with zoster or postherpetic neuralgia. It should be stressed that while occasionally all symptoms may abate after the first injection, in most cases repeated injections are necessary. It is important that the physician identify the points of maximum discomfort as accurately as possible and administer the medication selectively into these areas. Extensive eruptions can be controlled by this technique. There were no controls for comparison in this study, the treatment having been used regularly after it gave relief to the first patient on whom it was tried. In some cases, however, attempts were made to inject one portion of a lesion with the active principle and others with saline solution alone. Where that was done, patients denied noting any improvement. It is believed that there is too much overlapping of nerve fibers to permit CALIFORNIA MEDICINE 9 The Western Journal of Medicine

5 clearcut distinction between the treated and the placebo-injected areas. Furthermore, the pain sensation is not localized clearly enough to allow the patient to distinguish smaller asymptomatic areas within a painful lesion. One patient did offer a control of sorts. He had a severe zoster of the trunk with intra-abdominal pain. With the injection treatment the cutaneous lesions and symptoms cleared quickly, but the visceral symptoms have persisted for more than two years. Comparison with other reported series makes it obvious that the treatment described is also effective in postzoster neuralgia. ADDENDUM. After the foregoing report was written, normal saline solution was substituted for procaine as a diluent. No change was made in the dosage or form of the triamcinolone. Fourteen more patients were treated by this combination of Aristospan in saline solution, making a total of 50 patients treated. Three had postzoster neuralgia. In one patient there was complete alleviation of symptoms. In another, the results were "good" and in the third, the benefits obtained were considered "fair." Nine of the 11 patients with acute zoster had prompt and complete clearing. One did not return for further therapy or observation after the first injection. In one, postherpetic neuralgia persisted. This patient, who was decidedly senile, produced severe excoriations in the involved area. She was treated also with triamcinolone in procaine without effect. Therefore, one can conclude that the procaine is not a factor in the results obtained. However, this change in the diluent eliminated the vertigo mentioned previously. An abscess in the injected area on the trunk developed in one patient of this additional group. TRADE AND GENERIC NAMES OF DRUGS Aristocort... triamcinolone... triamcinolone Aristospan Kenalog... triamcinolone Xylocaine... lidocaine REFERENCES 1. Epstein E, Allington HV: The treatment of herpes zoster. Arch Dermatol 76:408, Oct Epstein E: Treatment of herpes zoster and postzoster neuralgia bv the sublesional injection of triamcinolone and procaine. Acta Derm Venereol 50:69, demoragas JM, Kierland RR: The outcome of patients with herpes zoster. AMA Arch Dermatol 75:193, Feb Eaglstein WH, Katz R, Brown JA: The effects of early corticosteroid therapy on the skin eruption and pain of herpes zoster. JAMA 211:1681, Mar Sehgal D, Gardner WJ: Postherpetic neuralgia. Neurology 12:725, 1962 DIAGNOSIS OF HASHIMOTO'S THYROIDITIS "If Hashimoto's thyroiditis is suspected... we frequently will do a needle biopsy of the gland as an office procedure and in so doing the pathology can be established. If substantiated, the treatment is thyroid replacement medication. However, if this is the diagnosis and if the gland is treated medically, close observation is extremely important for six to twelve months because in 3 percent of our patients who were treated surgically (18 of 605) papillary cancers were found. Also lymphosarcoma is seen to coexist in the presence of Hashimoto's thyroiditis, again in approximately 3 percent of cases. So if the goiter does not disappear under medical management over a period of three to six months or if there's any evidence of increase in size of the gland during this period of time, then it becomes extremely important that the goiter be removed surgically to rule out significant pathology other than that which is suspected." -OLIVER H. BEAHRS, M.D., Rochester Extracted from Audio-Digest Surgery, Vol. 17, No. 1, in the Audio-Digest Foundation's subscription series of tape-recorded programs. For subscription information: 619 S. Westlake Ave., Los Angeles, Ca AUGUST 1971 * 1 15 * 2