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Nevralgia post erpetica: strategie terapeutiche

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Prof.ssa Alessandra Graziottin
Direttore del Centro di Ginecologia e Sessuologia Medica
H. San Raffaele Resnati, Milano

Dear Dr. Graziottin, I took the liberty to write you a message because I have been quite desperate the last eight months and I feel completely helpless. I scheduled already an appointment with you and I count the days until then. You helped my sister tremendously with her vulva vestibulitis and we are so thankful. My condition is quite different. I was diagnosed with herpes zoster (on my hip) in August (which was treated quite fast), but then after a series of yeast infections I had my first diagnosis of genital herpes. Since then the flare ups did not stop and it seems that I have a flare up every time I have my period. The worst thing though is that the pain never stops even after the herpes is gone (or appears to be gone) (the type of pain feels like inflammation or some sort of injury). I have been to almost every doctor in Athens (I live in Greece), some of them made things worse, some of them tell me that it is all in my head, one ended up burning me because she suggested pure alcohol for the herpes and I had to deal with the incredible pain of burning as well. My personal life has been destroyed, but this is not the worse, I am afraid that my professional life is close to be destroyed, I can barely work because I am always in pain. My life is meaningless and I cannot imagine living a life like this. I am really sorry for the long message and for sounding so negative, but I have been trying to stay hopeful until now and nothing changed. I understand that you are very busy and I am really thankful for having the appointment with you in a little more than a month. I was wondering if you could give me any direction, if there is anything I could do until then about the pain. I would really appreciate any guidance from you. Thank you so much for your time and consideration.
Sincerely, Cat
Dear Cat, I’m really sorry for the intensity of pain you are enduring, but also for the neglect you’ve been treated with.
My suggestions:
1) I can anticipate the visit, to examine you asap to start an effective treatment, the sooner the better. Please write and send us your mobile and personal email, so that I can reach you directly;
2) from your wording, I can anticipate that the most likely diagnosis is post-herpetic neuralgia, which is a very painful condition, the key feature being the so called “neuropathic pain”, that is a chronic, very intense pain that becomes a real disease in itself;
3) this kind of pain can be treated with a comprehensive treatment, addressing its many components. Please discuss this preliminary approach with your family doctor, to get the prescription:
- antiviral treatment, for at least 6 months: the most effective is valaciclovir chlorhydrate 500 mg, 1 capsule in the evening as a profilactic treatment; 1 cps twice a day when the herpes is in flare;
- alpha-lipoic acid (a supplement very active in the neuropathic pain), 300 mg twice a day;
- gabapentin 300 mg, starting with 1 cps around 9 pm;
- amitriptyline drops, starting with one drop with a glass of water at 8 pm and then titrating 1 drop more per day, until you reach 8 drops every evening and get on with this dosage;
4) eliminating the mestrual bleeding (and the inflammation that precipitate the recurrent herpes) with a continuous progestogen or a continuous pill (without the hormone free interval). This will further reduce the menstrual flares (see my paper «“The shorter, the better”: a review of the evidence for a shorter contraception hormone-free interval» listed below).
More help can be anticipated as soon as I’ll have the opportunity to confirm the diagnosis and the evaluation of other potential comorbidities.
Best personal regards and wishes for a satisfying recovery,
Alessandra Graziottin

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