Vol. 16, #2

Acupuncture And Moxibustion For Pain Associated
With Herpes Zoster Infection: A Series Of 189 Cases
Maria del Carmen Andrés Martín, MD
Juan Antonio Guerra de Hoyos, MD
Elena Bassas y Baena de Leon, MD
Miguel Vigára Diaz, MD
Maria José González Moreno, RN
Francisco Antonio Verdugo Morilla, MD

ABSTRACT
Background Despite treatment options for herpes zoster infection, many patients experience refractory pain and frequent side effects, especially elderly patients with cardiovascular disease. Therefore, pain associated with herpes zoster infection remains a challenge for effective management. Acupuncture and other Traditional Chinese Medicine modalities such as moxibustion and bloodletting have not been evaluated for this disorder.
Objective To determine if acupuncture and moxibustion could be helpful in cases of herpes zoster infection.
Design, Setting, and Patients Prospective case series (December 1998 to December 2003) of patients with pain associated with herpes zoster infection in a community general practice. A total of 189 patients were treated with acupuncture, moxibustion, auriculotherapy, cupping, bloodletting, and electroacupuncture. Data was collected over a 5-year period.
Intervention Auriculotherapy involved ear points Shen Men, Subcortex, Occiput, Lungs, Gallbladder, Liver, and points corresponding to dermatome from the French and Chinese charts. Warming needle moxibustion was placed at classic acupuncture points. Acupuncture involved skin puncture with filiform needle. Cupping applied heat to the air in a glass, creating a partial vacuum over the skin at certain points. Electroacupuncture at 5-10 Hz was applied at an intensity suited to individual patient tolerance. The bloodletting method used was pricking with a triangular needle at hand or feet points to obtain 1 or 2 blood drops. The main points used were GV 14, GV 20, CV 17, GB 20, GB 31, GB 34, GB 35, GB 41, TE 5, TE 6, LI 4, LI 11, SP 6, SP 10, ST 40, ST 36, HT 7, PC 6, Huatuo-Jiaji, Sheyan, and Longyan points.
Main Outcome Measures The effect of acupuncture, moxibustion, and related therapies on herpes zoster pain (using a Likert 3-point outcome scale) showed resolution, some improvement, or no improvement.
Results Five patients reported no improvement; 32, simple improvement; and 152, clinical resolution.
Conclusions Treatment of pain associated with herpes zoster infection with acupuncture and related therapies seemed to have good clinical results in diminishing pain, even in long-lasting disease (up to 5 years). Randomized clinical trials are needed to confirm the perceived efficacy of acupuncture from observational studies.
KEY WORDS
Herpes Zoster, Neuralgia, Pain, Acupuncture

INTRODUCTION
Acute herpes zoster is caused by reactivation of latent varicella zoster virus (VZV or human herpesvirus 3). The virus persists for years in the dorsal root ganglia of cranial or spinal nerves after resolution of the original infection. As cellular immunity wanes with age or immunocompromise, the virus is transported along peripheral nerves, producing an acute neuritis.1,2 Herpes zoster is characterized by a painful, unilateral vesicular eruption usually in a restricted dermatomal distribution.3

Pain associated with herpes zoster infection can be classified as acute herpetic neuralgia (pain preceding or accompanying the eruption of rash that persists up to 30 days from its onset), subacute herpetic neuralgia (pain that persists beyond healing of the rash but which resolves within 4 months of onset), and postherpetic neuralgia (pain persisting beyond 4 months from the initial onset of the rash).4

While herpes zoster is reported in all age groups, the incidence of acute herpes zoster infection increases with impairment of the immune system due to age, disease, or chemotherapy. The annual incidence among healthy people younger than 20 years is approximately 1-2/1000; 5/1000 for 20-49 years; 5-7/1000 for 50-79 years; and 10-11/1000 for those older than 80 years.5-7 Herpes zoster is also several times more common in patients with cancer or HIV infection.8

Similarly, the probability of developing postherpetic neuralgia increases with advanced age, but the exact incidence is a matter of considerable debate and depends on when it is measured after acute infection. There is no agreed time point for diagnosis. Most studies agree that postherpetic neuralgia is rare in children. Estimates in adults range from 2%-6% in patients younger than 60 years to as many as 47%-70% of untreated adults older than 70 years.5,6

The major risk factor for postherpetic neuralgia is age; other risk factors are greater acute pain and greater rash severity.4,9-11 Advanced age is associated with increasing severity and persistence of postherpetic neuralgia symptoms, and a uniform decline in cell-mediated VZV-specific immunity has been documented in older individuals.1 Approximately 4% of individuals will experience a 2nd episode of herpes zoster.12,13 No other risk factor has been found to predict consistently which people with herpes zoster will experience continued pain.

Acute zoster is most commonly characterized by the unilateral eruption of a painful vesicular or bullous rash in a dermatomal distribution.10 Many patients experience fever, dysesthesias, malaise, and headache several days before the vesicular dermatomal eruption. Complete resolution of the rash occurs within 3-4 weeks.12

Thoracic (especially T4 to T6), cervical, and trigeminal nerves are most commonly affected.14 Pain is the most common symptom of acute herpes zoster and may precede skin changes by days or weeks.15,16

Pain is typically described as a sharp or stabbing sensation, burning sensation, or even "allodynia" (pain evoked by normally non-painful stimuli such as light touch).16

Most cases of acute herpes zoster are self-limiting, although it may present complications including ocular, neurologic, bacterial superinfection of the skin (which can delay healing of the zoster lesions), and postherpetic neuralgia.12,17 Herpes zoster is not always limited to a spinal nerve distribution but may also extend centrally, which can result in meningeal inflammation and clinical meningitis. Occasionally VZV reactivation affects motor neurons in the spinal cord and brainstem, resulting in motor neuropathies.6 Approximately 10%-24% of all patients with herpes zoster will develop postherpetic neuralgia18; individuals older than 60 years account for 50% of the cases, and 35% of patients older than 60 years can evolve to develop postherpetic neuralgia.16

Pain associated with herpes zoster infection can cause significant suffering, particularly in elderly persons. Symptoms may be severe enough to interfere with sleep, appetite, or sexual function. In addition, symptoms may persist from months to years and cause profound psychosocial dysfunction, disability, and despair. The difficulty in treating herpes zoster means increased costs for individuals and health services.19,20

The treatment of herpes zoster is aimed primarily at earlier healing of lesions and prevention of complications. Randomized controlled trials and systematic reviews have found that oral antiviral agents (acyclovir, famciclovir, valaciclovir) are effective to reduce pain at 1-3 months and to reduce the prevalence of postherpetic neuralgia at 6 months, although the effect is moderate. These drugs must be administered within 72 hours from the onset of symptoms and have a good safety profile. Netivudine has a similar effect.21-24 Other drugs such as amantadine, levodopa, amitriptyline, and idoxuridine are of unknown effectiveness in preventing herpes zoster complications. Corticosteroids are considered to be ineffective or even harmful.24 Drugs considered to have a moderate effect in treating established postherpetic neuralgia are gabapentin and tricyclic antidepressants.23,25,26

Despite these treatment options, many patients experience refractory pain and frequent adverse effects, especially elderly patients with cardiovascular disease. Therefore, pain associated with herpes zoster infection remains a challenge for effective management. Acupuncture and other techniques from Traditional Chinese Medicine such as moxibustion and bloodletting have not been evaluated for this disorder. However, Chinese case series report good treatment results but lack rigorous design.27-29 We began a pain program at our primary care institution and collected cases of patients with herpes zoster–associated pain to determine if these techniques could be helpful in such cases.

METHODS
Patients from 2 urban primary care settings (CS "Torreblanca" and CS "Cerro del Águila," Sevilla, Spain; National Health Service) were diagnosed by their general physician as having pain associated with herpes zoster infection (acute herpetic neuralgia: pain preceding or accompanying the eruption of rash that persists up to 30 days from its onset; subacute herpetic neuralgia: pain persisting beyond 4 months from the initial onset of the rash; or postherpetic neuralgia: pain persisting beyond 4 months from the initial onset of the rash). All patients were treated with acupuncture in the pain program at the same clinic.

Prospective data were collected from every consecutive patient admitted to the pain program from December 1998 to December 2003, without limitations on age or comorbidity.

Treatment
Auriculotherapy involved placement of vaccaria seed on both ears after sterilization with iodine, with no further manipulation of the patient. Ear points used were Shen Men, Subcortex, Occiput, Lungs, Gallbladder, Liver, and points corresponding to dermatome, from the French and Chinese charts. Where possible, the seeds were placed on the points of greatest sensitivity to pressure.

The moxibustion technique used (warming needle moxibustion) was the attachment of moxa (Artemisia) purchased cones to needles inserted at classic acupuncture points. Acupuncture involved skin puncture with filiform needles (Hao type 30G). Cupping, used in a standard fashion, applied heat to the air in a glass, creating a partial vacuum over the skin at certain points.

Electroacupuncture was used to increase acupuncture point stimulation in some cases. Dense-dispersed waves at 5-10 Hz were applied at an intensity suited to individual patient tolerance. The bloodletting method used was pricking with a triangular needle at hand or feet points to obtain 1 or 2 blood drops.

The main points used were GV 14, GV 20, CV 17, GB 20, GB 31, GB 34, GB 35, GB 41, TE 5, TE 6, LI 4, LI 11, SP 6, SP 10, ST 40, ST 36, HT 7, PC 6, Huatuo-Jiaji, Sheyan, and Longyan points. (The Sheyan points are found on the thumb, midway between the corners of the nails and the distal crease. The Longyan points are located in the equivalent position on the big toes.)

TECHNIQUE
The type of treatment we chose was dependent on the type of diagnostic categories:

  • Cases of acute herpetic neuralgia were treated by pricking unilateral Sheyan or Longyan points, depending on thoracic or abdominal dermatomal distribution; GV 14 with warming needle and cupping, and classic acupuncture body points as needed.
  • Subacute and chronic cases were treated with electroacupuncture at Huatuo-Jiaji points corresponding to dermatomal lesion, and adjuvant classic somatic points (as needed for itching, insomnia, or other symptoms).

We used Traditional Chinese Medicine rationale for Bi syndrome for heat and damp. using local and distant points of channels involved, experience points, and Huatuo Jiaji points for nervous system diseases (in an attempt to individualize point selection depending on patient symptoms and keep major points as Huatuo Jiaji constant).

We inserted 1-10 needles (commonly only 4), then elicited De Qi by twirling the handle clockwise and counterclockwise at 100 times/ min. After De Qi was achieved, needles were not manipulated during retention time; after 15 minutes, needles were removed and vaccaria seeds were placed over the ear points. Needles placed at Huatuo Jiaji points were connected to terminal wires of the electroacupuncture device and were stimulated during retention time with dense disperse waves of 5-10 Hz at sufficient intensity to elicit light muscular twitching.

Patients received 1 treatment every week for the 1st 4 treatments and then, once every 2 weeks to a maximum of 10 treatments from the starting session.

We used Chinese-made filiform needles (Hao type), 0.32 gauge, 1 or 1.5 cun lengths, for a depth insertion of 1 cun (imported by Hispasia S.S. C/Virgen de Aguas Santas, Sevilla and Electronic Acupuntoscope Model WQ-6F, manufactured in Beijing, China). We did not use herbs, light, music, or other adjuvant interventions.

Acupuncture treatments were administered by the authors, (2 licensed acupuncturists, both with more than 4 years' experience in a primary care pain program with acupuncture and moxibustion techniques, treating several thousand cases of pain patients).

Outcomes
Two members of the investigation team registered and processed data from every consecutive patient: sex, age, diagnosis, total time elapsed from start of condition to start of treatment, number and type of treatments applied, and patient results. The latter was assessed by patient symptoms up to the end of treatment. They included self-reported pain, healing of skin lesions, and reasons for discontinuing treatment. The following 3-point Likert scale was used to describe results according to the patient:

  • Clinical resolution: no pain and no skin lesions at the end of treatment.
  • Simple improvement: improvement from pretreatment level, but residual pain at the end of treatment.
  • No improvement: no change from pretreatment pain level at the end of treatment.
    The patients' pain-worsening was not included on the scale because no patient treated reported worsening of the pain during or after treatment. There were no adverse reactions or complications attributed to the treatment during or after treatment.

RESULTS
In our study, there was a clear preponderance of women (64.6%) over men (35.4%). This imbalance was most prevalent in the age range of 60-69 years (68 cases), then 70-79 years (37 cases) (Table 1). The most prevalent diagnostic category was subacute herpetic neuralgia (47%), followed by acute herpetic neuralgia (37.5%), and postherpetic neuralgia (12.3%) (Table 2).

Table 1. Demographic Details

Sex

No. (%) of Patients

Male

67 (35.4)

Female

122 (64.6)

Age, y

20-29

18

30-39

21

40-49

18

50-59

18

60-69

68

70-79

37

80-89

9

Most patients started acupuncture treatment within 2 months of the onset of symptoms (37.5% up to 1 month, and 34.4% up to 2 months), but 12.2% had a long-lasting condition before treatment (>4 months up to 3 years) (Table 2). There was no clear relationship between the results of treatment and the age range or duration of symptoms at presentation.

The most frequently used treatments were auriculotherapy, 2.6 sessions per patient (average per patient), and acupuncture, 2.6 sessions per patient. The other treatments were used mainly to help reach an effect in chronic cases or low responders. Eighty-five percent received only up to 3 treatments (3-4 weeks); most of them were acute or subacute cases; 7.4% received 7-12 treatment sessions, mainly long-lasting postherpetic neuralgia cases (Table 3). Only 32 patients (16.9%) reported pain improvement from pretreatment level, but still reported light pain at discharge; 5 (2.6%) had no improvement after 1-2 sessions or they gave up treatment after the 1st treatment session because they disliked needling. The rest of the patients completed treatment until discharge (discharge due to pain having disappeared or diminished, according to patient and physician opinion).

Pain worsening was not included in outcome categories because no patient treated reported worsening of the pain during or after treatment. There were no adverse reactions or complications (dizziness, local or general infections, pain worsening after acupuncture) resulting from the treatment or the herpesvirus infection.

Table 2. Diagnostic Categories

Diagnosis

No. (%) of Patients

Acute herpetic neuralgia

71 (37.5)

Subacute herpetic neuralgia

89 (47)

Postherpetic neuralgia

23 (12.3)

Time from pain onset to treatment, mo

0-1

71 (37.5)

1-2

65 (34.4)

2-3

12 (6.3)

3-4

18 (9.5)

5-6

6 (3.2)

6-12

11 (5.8)

12-48

3 (1.6)

48-60

3 (1.6)


DISCUSSION
Traditional Chinese techniques such as acupuncture and moxibustión could be integrated with orthodox Western therapies to fill the effectiveness gap in some pain problems such as herpes zoster–associated pain to prevent or reduce pain with minimal adverse effects of treatment. We believe that effect must be proven with a rigorous research design such as a randomized controlled trial (RCT). As a preparatory step to conducting an RCT, we attempted to substantiate whether we could achieve similar results as described by Chinese authors (although the research designs they commonly used are of a very low level).28-30

We conducted a prospective case series, without a control group, including every patient sent to a pain program, to validate these techniques as deserving further investigation. Our results appear similar to those of Chinese authors. Results showed a trend to diminish pain intensity and duration for acute, subacute, and chronic cases even in elderly patients, causing minimal harm.

We acknowledge that case series are prone to observer bias and confounding factors, and that solid conclusions will only be reached with robust research design such as RCTs.21-23 However, our experience in this study is a step toward designing a research protocol for an RCT on acupuncture's effect on herpes zoster–associated pain.

Table 3. Details of Treatments and Outcomes

No. of Treatments

No. (%) of Patients

1-3

162 (85)

4-6

13 (6.9)

7-12

14 (7.4)

Treatment type

No. of Sessions

Auriculotherapy

2.6

Cupping

0.37

Bloodletting

0.14

Moxibustion

0.31

Acupuncture

2.6

Outcomes

No. (%) of Patients

Clinical resolution

152 (84.4)

Simple improvement

32 (16.9)

No improvement

5 (2.6)
CONCLUSION
Treatment of pain associated with herpes zoster infection with acupuncture and related therapies seemed to have good clinical results in diminishing pain, even in long-lasting disease (up to 5 years). Though conclusions from a case series without a control group are prone to observer bias and confounding factors, our results appear similar to those of Chinese authors and show a trend to diminish pain intensity and duration for acute, subacute, and chronic cases, even in elderly patients, causing minimal harm. We believe that acupuncture for this disease warrants consideration and should be tested with vigorous research designs, such as RCT, to reach solid conclusions.

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AUTHORS' INFORMATION
Dr Maria del Carmen Andrés Martín is a General Practitioner in private practice in Sevilla, Spain.
Maria del Carmen Andres Martin, MD
C/Avda Eduardo Dato nº54 3º B DP 41005
Sevilla, Spain. 34 954632555
Dr Juan Antonio Guerra de Hoyos is a General Practitioner in Centro de salud de Torre-
blanca, Spain.
Juan Antonio Guerra de Hoyos, MD*
C/La Maria 26, DP 41008
Sevilla, Spain
Phone: 954353964
E-mail: med010042@saludalia.com

Dr Elena Bassas y Baena de Leon is an MD Clinical Analyst at Riotinto Hospital, Andalucia
Public Health Service in Huelva, Spain.
Elena Bassas y Baena de Leon, MD
C/ Pastor y Landero 23-25, 2º A
DP 41001
Sevilla. Spain
Phone: 31 34 954213758
E-mail: turku62@hotmail.com
Dr Miguel Vigára Diaz is a General Practitioner (MD) at Andalusia Public Health Service.
 

Maria José González Moreno is a Nursing Professor at Health Sciences School, Sevilla University in Sevilla, Spain.
Maria José González Moreno, RN
E-mail: mjgonza@hus.es
Dr Francisco Antonio Verdugo Morilla is a General Practitioner in private practice in Sevilla, Spain.
Francisco Antonio Verdugo Morilla, MD
E-mail: faverdugo@hotmail.com

*Correspondence and reprint requests

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