Shingles is a condition characterized by a painful, blistering skin rash. This rash can affect any part of the body. The medical name for shingles is Herpes Zoster. It is the caused by the same virus that causes chicken pox. People who have had chicken pox are potentially at risk for developing shingles later in their life. Patients who have never had chicken pox can get this from individuals who have an active attack of shingles, as the rash is contagious. Shingles can appear anywhere on the body but tend to follow the distribution of the nerves, as this is where the virus lives. Although severe in any part of the body, facial involvement around the eye presents an even greater problem. If shingles involves the upper face, the eye can be affected, potentially leading to eye complications including infection and corneal ulceration. The treatment of an acute attack of shingles involves giving a patient one of the specific antiviral agents such as Zovirax (acyclovir), Famvir (famcilovir) or Valtrex (valacyclovir) along with Prednisone to shorten the duration of the attack and to lessen potential for development of postherpetic neuralgia. Postherpetic neuralgia develops in about 20% of patients who have had shingles. Shingles is much more common in individuals over the age of 50. Approximately 1 million people in the United States get shingles every year.

The FDA has recently approved a shingles vaccine, Zostavax, to aid in the prevention of this condition. This is an injectable medication that requires only one treatment. The Center for Disease Control has recommended that all eligible patients over the age of 60 be immunized. The requirements for receiving the vaccine are as follows: you are in good health and must not have any condition that would lower your immune system function. Conditions that lower your immune system include diabetes, cancer, chemotherapy or steroid therapy, active tuberculosis, excessive alcohol consumption or acute illnesses such as pneumonia. The best available treatment to prevent shingles is this vaccine.

Postherpetic neuralgia (PHN) is an extremely painful condition that follows after having an attack of shingles. Although the rash and blisters clear, affected patients are left with a searing, burning painful sensation on the skin, in the area of the rash. This is a form of peripheral neuropathy. Their skin can be so sensitive that even clothing or bed sheets brushing up against the skin can trigger severe pain. Unfortunately, narcotic pain killers do not help in reducing this pain. Alternate treatment with nonnarcotic medications is necessary. Commonly used medications for treatment of PHN include the anticonvulsants such as Tegretol, Lyrica, Neurontin, Trileptal and Topamax. Other agents that are helpful are the tricyclic compounds such as amitriptyline, imipramine and nortryptiline. A novel approach to treatment involves using Lidoderm patches. These are lidocaine embedded patches that control the pain without having to take an oral medication. These can be used in combination with oral medications to better control the pain of PHN. Most patients will have clearing of their PHN within 1-6 months. Rarely it can persist for a longer period of time. For patients who have received the shingles vaccine, who subsequently develop shingles, the incidence of developing PHN is significantly reduced and the severity of the symptoms are generally less. Please contact Sarasota Neurology for more information.

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The FDA has approved a new medication therapy for the treatment of Parkinson’s disease. The new drug is rotigotine (Neupro), which is in the family of dopamine agonists. Dopamine agonists mimic the effects of levodopa (Sinemet) without having to go through chemical transformation. Other dopamine agonists include Mirapex and Requip. Neupro is different in that it comes in the form of a patch. This has the advantage that the medication is delivered continuously through the skin, while you are wearing the patch. Theoretically, this would provide a more even blood concentration of medication throughout the day. Patients using Neupro should not be taking one of the other dopamine agonists. This patch can be used alone or in combination with other Parkinson medications, to help improve the daily function of patients affected with Parkinson’s disease. Side effects include low blood pressure, foot swelling, hallucinations and stomach upset – just like the other dopamine agonists. Neupro can also cause contact dermatitis (rash) from the patch adhesive. This is similar to what some patients experience with bandages and medical tape. The dopamine agonists help Parkinson patients in many ways including use of less Sinemet and decreasing dykinesias. Dykinesia is an involuntary movement that can affect the head, shoulders, arms and legs. The development of dyskinesia is related to the amount and duration of use of Sinemet.

Another new medication that was approved by the FDA is a drug called Azilect (Rasagiline.) This is in the class of medications known as the MAO-B inhibitors. MAO is a an enzyme in the body that breaks down dopamine. By inhibiting MAO-B, Azilect allows more dopamine to enter the brain. It also theoretically slows the breakdown of dopamine. Dopamine is the main brain chemical transmitter that is lacking in Parkinson patients. This drug can be used by itself or in combination with other Parkinson medications, particularly levodopa (Sinemet.) Unfortunately, like other Parkinson drugs, Azilect does not work for everyone.

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“Doctor, my feet burning and are numb.” That is a frequent complaint that I here from my patients. Peripheral neuropathy, a nerve condition, commonly starts in the toes or the feet. Affected individuals may feel this as a numbness, tingling, raw or burning sensation. These symptoms very slowly progress over many years. The most common type of neuropathy affects the nerves that supply sensation in the feet. As the condition worsens and spreads up the legs, it can start to affect the fingers and hands as well. Patients who present with these symptoms all need to be screened for diabetes and vitamin B12 deficiency. Other common causes for sensory neuropathy can include chronic, daily alcohol consumption, kidney failure and chemotherapy. For many patients that have sensory neuropathy, a cause is never found. There are two types of sensory neuropathy: painless and painful. While there is no cure for sensory neuropathy, it is rarely disabling. For patients with painless neuropathy, no treatment is necessary other than treatment of any condition that may be causing the symptoms (diabetes, stop alcohol, etc.) For patients with painful neuropathy, many nonnarcotic treatments are available.

Lyrica is a new antiseizure medication that was approved by the FDA for treatment of painful diabetic neuropathy. Many neurologist also use this drug for treatment of other painful neuropathies with great success. Many of the neuropathy treatment drugs are in the anticonvulsant (antiseizure) medication group. These include Neurontin (gabapentin), Tegretol (carbamazepine) and Trileptal. Some clinicians have had success with Topamax for certain neuropathic pain syndromes. If a patient has difficulty tolerating one drug or a particular drug is not working, then they can be switched to one of these other agents. The other class of commonly used medications used to treat symptoms of painful neuropathy are the tricyclic antidepressants. These agents have a mechanism that blocks pain impulses at very low doses. Since many patients are bothered more by their pain at night, these agents have the added benefit of assisting in going to sleep. They are inexpensive and not habit forming. It needs to be noted that although these medications are labeled “antidepressants” their use to treat pain and headache conditions has nothing to do with treatment of depression. Most patients that are on tricyclic antidepressants are not depressed.

A newer, novel approach to treatment of painful neuropathy is to use a patch called Lidoderm. This is a patch with a special form of Novocaine embedded in it. Patients can put the patches over the area of pain, frequently with good relief. One patch is good for about 24 hours. There is no additional numbing sensation from the patch itself. It is important that patients with neuropathy understands that there is no treatment that will give the the sensation back but only to control the pain or discomfort associated with the neuropathy. Lidoderm has FDA approval for treatment of postherpetic neuralgia, a very painful condition seen after an attack of shingles.

Combinations of various modalities of neuropathy treatment are frequently used to provide patients with an improved quality of life. There are other less commonly used drugs and treatments that sometimes help patients function better. It is important to note that narcotic pain medications are not mentioned here as this class of drugs is notoriously ineffective in treating nerve pain. Additionally, they are habit forming, addictive and tend to lose their effect after a while, requiring even higher dosages which lead further to addiction. In summary, if you or someone you know has painful neuropathy, get them in to see a neurologist that has training in treating this condition.

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