Manual acupuncture, electro-acupuncture and low-level Laser therapy in management of Herpes Zoster complicated by right side facial palsy: a case report.
Summary Herpez zoster (HZ) or shingle is a common presenting problem in both general practice and pain clinics, particularly when it is associated with one or more complications such as post-herpetic neuralgia and facial paralysis. The case presentation in this article reports a successful use of a treatment combination (manual acupuncture, electroacupuncture and low-level laser therapy) in the management of herpes zoster complicated by right side facial palsy. After 6 combined acupuncture treatments over 2-week period, the patient had a complete cure.
Herpes Zoster is known as a viral infection which should be treated within 48-72 hours of its onset in order to achieve an optimal management (1). Typically, the shingles occurs only along the distribution of one single spinal nerve appearing in a band or a patch round the trunk; or down the arm; or on the buttock, or down the leg. Not like chicken pox, shingles can be very severe infection that could cause long lasting pain (post-herpetic neuralgia) (Table 1).
Table 1 FACTS ON HERPES ZOSTER (SHINGLES)
1. The word herpes is derived from French and Latin meaning (to creep) and zoster is a belt or girdle. It has been described as “a belt of roses from hell”. While Shingles is derived from the Latin term "cingulatus" meaning "to encircle or wrap around".
2. It is known that 20% of those people who have had chicken pox will get zoster at some time during their lives. Fortunately, most people will get zoster only once. Many peoples in the UK are infected with varicella-zoster virus (VZV) in childhood and later in adult hood may develop herpes zoster. However, Hepres zoster can occur at any age but it is more common after age of 50.
3. A reactivation of the chickenpox virus lying dormant for many years in the root of a nerve in the brain or spinal cord may be brought up by stress or by the loss of natural immunity as in aging. The only Western treatment options for acute zoster are antiviral medications and corticosteroids.
HZ is caused by reactivation of latent varicella-zoster virus (Table 2). The virus can lie dormant for many years in the sensory nerve ganglia and when reactivates it produces a vesicular painful rash along the distribution of a dermatome. It is most common in elderly patients and immunosuppressed patients (especially HIV infection). The acute stage of herpes zoster is generally self-limited, but systemic complications may be fatal. One of the major chronic complications is post-herpetic neuralgia. Most cases do not require medical attention, but between 0.10% and 0.75% are complicated by central nervous system (CNS) involvement (2) such as, cerebellar ataxia, generalized meningoencephalitis, and rarely--when salicyclates are concomitantly used--Reye's syndrome (reactivation of VZV within the facial nerve ganglion) (3). Patients with this syndrome develop zoster oticus, peripheral facial palsy, regional adenopathy, vertigo, and anesthesia of the anterior two thirds of the tongue (4).
Table 2. Etiology and Pathophysiolohy
1. Although no body knows the causes which reactivate or "awaken" herpes zoster virus in healthy people, a temporary weakness in immunity may let the virus to multiply and move along nerve fibres toward the skin. It may be associated with aging, a suppression or malfunction of the immune system,
2. There are certain diseases that might weaken immunity such as cancers, leukemia or lymphoma, and AIDS. Furthermore, trauma, stresses and medical treatments including chemotherapy or radiation for cancer, drugs taken to prevent rejection of transplanted organs, and cortisone medications taken for a long time for any reason, may also lower immunity and trigger a zoster attack.
3. The inflammatory lesions occur in the sensory ganglia and in the skin of the associated dermatome and continue to form for a period of 3 to 5 days with a total duration of the disease being 10 to 15 days.
4. Herpes zoster virus attacks the dorsal root ganglia producing a vesicular eruption and neuralgic pain along the dermatomes supplied by sensory nerves of the affected root ganglia (sometimes, the inflammation can involve the posterior and anterior horns of the gray matter, the meninges, and the dorsal and ventral roots). Thoracic dermatomes are most commonly affected (50% to 60% of all cases), but trigeminal (10% to 20% of cases), cervical (10% to 20% of cases), lumbar (5% to 10% of cases), and sacral dermatomes (<5% of cases) may all be involved (5). Histopathological examination of a scrape skin cells and laboratory test of the fluid from the blister may confirm the diagnosis.
5. According to the traditional Chinese acupuncture theory the causative factor is: the invasion by exogenous Wind and Cold which invade the meridians traversing the face and disrupt the flow of Qi and Blood, preventing the vessels and muscles from receiving the necessary nourishment (6).A CASE REPORT
HISTORY AND PRESENTION (Table 3)
A 71-year male gray-haired white male self-referred, seeking acupuncture treatment for HZ on the right neck and post-auricular regions associated with facial paralysis on that side. He first complained of prodromal symptoms of flulike such as fever, chills, and gastrointestinal symptoms for two days. Then he started to develop an odd sensation in the skin over the right side of the neck ascending to behind the right ear that gradually turned into pain (Table 3). In these areas, the skin lesion of an extensive vesicular rash begun as a series of well circumscribed, erythematous, maculopapular skin eruptions that follow sensory dermatomes. Twenty-four hours after the rush appearance he noticed that the area on his right side of neck and up to behind the right ear was covered by extensive mass of ulcerated abrasions. This picture was associated with an acute right facial paralysis as the patient was unable to close her right eyelid, and experienced difficulty with drinking and mastication. During the appearance of these sings and symptoms he visited the family doctor and the diagnosis came as HZ associated with right facial paralysis. He has no past history of chicken pox or cold sores.Table 3. CLINICAL PICTURE OF HZ (7)
1. HZ usually appears as unilateral red patches that soon turn into small or large groups of dermatomal vesicular eruptions that look like chicken pox, commonly involving the thoracic (50%) or facial (40%) dermatomes (2).
2. The rash usually develops a crust within 10 days, while the vesicular eruptions generally last for 2-3 weeks. These lesions start out clear but pus or dark blood collected in the blisters before they crust over (scab) and begin to disappear.
3. The patient may present for one to three days’ prodromal symptoms of deep aching, burning pain, tingling or extreme sensitivity in one area of the skin or pruritis in the affected area before a red rash appears.
4. Even after recovery from the pain of shingles, with or with usual conventional treatment, patients will go on to develop post-herpetic neuralgia
On examination, new crops of blebs were seen while the older ones started to crust over with some few crusts dropped off leaving behind a red skin very tender to touch.
Furthermore, there were clear signs of right facial paralysis associated with symptoms of pain and burning sensation. This can be explained by the fact that a rash on the neck and lower part of the face, involving the trigeminal and cervical nerves, may be associated with paralysis of the facial nerve and loss of taste
The management of HZ by drugs (Table 4) is not usually successful and can carry with it some side effects and expensive. While acupuncture is proved to be an
Table 4. Conventional treatment of HZ
1. Symptomatic measures (rest as much as possible.
2. Analgesic therapy (simple painkillers, such as aspirin or paracetamol, regularly).
3. Anti-viral therapy (Antiviral compounds, namely aciclovir, famciclovir and valaciclovir) (8).
4. Skin therapy: Topical application of creams with an ingredient such as capsaicin, a local anaesthetic drug or a non-steroidal anti-inflammatory drug (NSAID) and aspirin-in-chloroform and calamine lotion.
5. Other terapy: the tricyclic drugs (eg., amitriptyline, nortriptyline) for treatment of post-herpetic neuralgia. About 60-70% of patients with post-herpetic neuralgia respond well to treatment with amitriptyline introduced at a low dose with step-wise increases. The remainder are considered to be intractable (resistant to treatment).
6. Nerve blocks: Anesthetic approaches include local infiltration, peripheral or epidural nerve blocks, and sympathetic blocks.
effective measure in aborting signs and symptoms of herpes zoster. However, acupuncture management of herpes zoster is a time-consuming procedure, as each session of treatment lasts for about 30 minutes to one hour. Six treatment sessions (a combination of manual acupuncture, electro-acupuncture and laser acupuncture) twice weekly were given to the patient.
In each session, disposable, sterilised and filiform needles of 0.5-1.0 inch long and 30 gauge were used. The therapeutic effect was found to be at its best when the patient had a feeling of transient shock at the site of the needle insertion on one acupuncture point (GB 34), propagating along a variable distance from that site (usually to the same side foot) (9). Both mild manual stimulation with a needle rotated at 60-90 degrees and strong manual stimulation with a needle rotated at 90-180 degrees were used with either reducing or reinforcing for about 10 minutes (10). The following classical acupuncture points were used in the treatment:
Specific points for pain (treated bilaterally):
1. Li 4
2. Liv 3
Local points for mild stimulation (treated on right side only):
1. Ah-shi points
2. Points near to the affected area
3. Points on the Du channel
4. Point Ex. 21 on the corresponding dermatome
5. St. 2, St 4 and St 7
6. GB 14
Distal points for strong stimulation (treated bilaterally):
1. Li 4, Li 11
2. SJ 5, SJ 8
3. Si 3
4. St 44
5. St 36
Electrical stimulation was carried out after manual needle stimulation, using low frequency of 3-10Hz ( AMBD Acupunctoscope Stimulator, Acumedic) for 10 minutes. A combination of paired points were used for electrical stimulation: Li 4 (++) and SJ 5 (--); SI 3 (++) St 44 (--) only.
Laser acupuncture (Infralaser 40, Acumedic) is applied after the manual and electroacupuncture treatment. Radiation of only local acupuncture points was used. The period of treatment at each point may range from 10-40 seconds. The intensity of the laser beam was very low so that there was no danger of damage to the skin, underlying tissues or the patient’s eyes.
PATIENT RESPONSE AND OUTCOME RESULTS:
The patient’s skin lesions were cleared after two sessions of a combination treatment. As the treatment progressed, the patient began to show improvement in right facial paralysis. After the completion of 6 acupuncture sessions the patient was considered clinically cured; he showed significant motion in his forehead and had total closure of his eye with maximal effort. (Figures: before and after treatment).
Acupuncture therapy in acute phase of HZ is usually directed at preventing postherpetic neuralgia and other associated complications, whereas in chronic, or remedial, phase, it is aimed at minimizing already existent pain (11). On one hand, most western therapies are helpful to some people but sometimes carrying high probability of risk and side effects (12). Despite this, however, the scientific evidence of efficacy from double blind and controlled studies on these therapies is often lacking. On other hand, Traditional Chinese Acupuncture has accumulated many previous experiences for treating this disease as the bulk of published work to date supports the use of acupuncture (11,12, 13, 14) and laser therapy (15, 16) for treatment of herpes zoster and its complications.
This patient, in our opinion, was in late stage of acute phase and responded well to the combination treatment of manual acupuncture, electroacupuncture and laser therapy and achieved a full recovery in only three weeks. This is in agreement with the previous report on the management of HZ by acupuncture (14). Other most significant outcome of the combination treatment course was the complete recovery from the right facial paralysis. Previous report by Liu (17) indicated that100% of patients were markedly improved or cured when acupuncture was initiated within three days post-onset in 684 cases of facial nerve paralysis. The acupuncture management of this patient may be an example of a significant method in treating Hz associated with facial paralysis.
A need for more scientific studies based on well-constructed single or double blind comparative trials is necessary to establish the effectiveness of acupuncture management of herpes zoster (18).
1. International Herpes Management forum: Inaugural Meeting (1993) Wellcome Foundation Ltd.
2. Boughton CR: Varicella-zoster in Sydney. II. Neurological complications of varicella.
Med J Aust , 1966, 2:444-447.
3. Whitley RJ: Encephalitis caused by herpes viruses, including B virus, in Scheld WM, Whitley RJ, 4. Durack DT (eds): Infections of the Central Nervous System. New York, Raven Press, 1991, pp 41-86.
4. Elliott KJ: Other neurological complications of herpes zoster and their management. Ann Neurol ,1994, 35(suppl 10):S57-S61,
5. Mazur MH, Dolin R: Herpes zoster at the NIH: A 20-year experience. Am J Med,
6. O'Connor J, Bensky D. Acupuncture a comprehensive text. Seattle: Eastland Press
7. Nikkels AF, Pierard GE: Recognition and treatment of shingles. Drugs,1994, 48:528-548.
8. Herne K, Cirelli R, Lee P, et al: Antiviral therapy of acute herpes zoster in older patients. Drugs Aging 8:97-112, 1996.
9. Tukmachi, E.S.A. Frozen shoulder: a comparison of Western and Traditional Chinese
Approach and a Clinical study of its Acupuncture Treatment. Acupuncture In
Medicine, (1999), 17(1): 9-21.
10. Tukmachi, E.S.A. Migraine and Acupuncture: Clinical Approach. International Journal
of Alternative and Complementary Medicine, (1994) 12(3): 15-19.
11. Coghlan, CJ Herpes zoster treated by acupuncture. Central African Journal of Medicine,
1992, 38(12): 466-7.
12. Whitley RJ, Straus SE: Therapy for varicella-zoster virus infections: Where do we
stand? Infect Dis Clin Pract, 1993, 2:100-108.
13. Nielsen, SE Treatment of Herpes zoster with acupuncture. In: Ariaf et al., eds. Recent
Progress in anaesthiology and resuscitation. Excerpta medica, 1975, 732-4.
14. Boaler, J Acupuncture in the management of Herpes zoster. Acupuncture in Medicine,
1996, 14: 80-83.
15. Moore KC Cost effective benefits of the use of laser therapy in the treatment of
intractable postherpetic neuralgia. Proceedings of 3rd world congress, international
Society for low power laser Applications in Medicine, Bologna, Italy.
16. Glennie-Smith K Low reactive-level laser therapy in the treatment of post-herpetic
neuralgia. Acupuncture in medicine, 1993, 11(1): 11-5.
17. Liu YT. A new classification system and combined treatment method for idiopathic
facial nerve paralysis: report of 718 cases. Am Jacup, 1995; 23(3),205-210.
18. Volmink, J, et al. Treatments for post-herpetic neuralgia: a systematic review of randomized controlled trials. Family Practice, 1996; 13(l):84-91.