INTRODUCTION
Acute herpetic pain has been noted to markedly impact
health-related quality of life.1,2 No studies have
attempted to quantify the impact of herpetic pruritus,
acute or postinfectious, on quality of life, though epidemiologic
data give voice to its relative frequency (up to
17% of acute cases) and individual reports bring to light its
negative impact in selected cases.3-5 A proposed mechanism
of herpetic pruritus and neuralgia cites neuronal necrosis
and subsequent imbalance of pruritogenic and nociceptive
inputs as the culprit.5 Unfortunately, many drugs that alleviate
neuropathic pain do not have the same efficacy for relief
of neuropathic itch in the individual patient.6
Case Report
A 64-year-old man with Crohn disease was admitted for
enterocutaneous fistula takedown. He did not have a prior
history of herpes zoster. During his postoperative stay, he
had hyperalgesia, erythema, and vesicles in a left V1 distribution
with ipsilateral conjunctivitis and keratitis (Figures 1
and 2). Treatment with intravenous acyclovir was begun, and
varicella zoster virus was confirmed with polymerase chain
reaction of blister fluid.
Three days after the skin eruption, the patient began to report
itch in the area. Over the next 2 weeks, this symptom progressed
to severe pruritus and burning pain, each rated by the
patient as 10/10 on the visual analog scale, initially localized
to the area of infection, and unrelenting. Over 3 days, the pruritus extended to include the bilateral scalp, though the pain
remained localized to the area of infection. Initial treatment
recommendations included wound care with dilute acetic acid
wet dressings and twice daily 2.5% hydrocortisone cream. The
patient reported that he had a decrease in his symptoms—
to 8/10 and lasting for several hours—with this regimen. This
treatment was continued for the remainder of his hospital
stay. Oral gabapentin therapy was begun at a dosage of 300
mg 3 times daily and was titrated to up to 400 mg 3 times daily
before his dismissal from the hospital, which occurred when
his renal function had normalized.
Low-dose oral opioid therapy was discontinued in favor of
nonopioid analgesics, given that opioids may cause considerable
pruritus in some patients. Topical lidocaine patches were
applied to intact surrounding skin every 12 hours. Therapy
with oral hydroxyzine (25 mg daily) was started; however, it
was used only intermittently because of the patient’s concern
about associated somnolence. After the combination of these
interventions, his itch was 7/10 or 8/10 for most of the day and
10/10 for the remainder.
At this point, the patient’s primary medical and surgical conditions
had stabilized; however, his recalcitrant pruritus and pain
prohibited his dismissal. Treatment of conjunctivitis and keratitis
consisted of erythromycin ophthalmic ointment initially.
Unfortunately, he also had an immune stromal keratitis, which
required the addition of ophthalmic corticosteroids.
