- Asploro Journal of Biomedical and Clinical Case Reports
- ISSN: 2582-0370
- Article Type: Case Report
- DOI: 10.36502/2021/ASJBCCR.6231
- Asp Biomed Clin Case Rep. 2021 Mar 10;4(1):66-71
Post-Herpetic Pain Managed According to The Recommendations of the Italian Society of Mesotherapy
Domenico Russo1, Massimo Mammucari2*, Silvia Natoli3, Enrica Maggiori2, Luciano Antonaci2, Renato Fanelli2, Chiara Giorgio4, Anna Rosa Catizzone5, Fiammetta Troili5, Alessandra Gallo5, Costanza Guglielmo5, Flora Canzona6, Dario Dorato5, Raffaele Di Marzo5, Stefania Santini5, Rodolfo Gallo5, Piergiovanni Rocchi5, Gianpaolo Ronconi7, Paola E Ferrara7, Michela Guarda1
1“San Marco” Hospice and Palliative Care, Latina, Italy
2Primary Care Unit, ASL RM 1, Rome, Italy
3Department of Clinical Science and Translational Medicine, Tor Vergata University, Rome, Italy
4Rehabilitation Unit, F Pirinei Hospital, Altamura (BA), Italy
5Italian Society of Mesotherapy, Rome, Italy
6Istituto Dermopatico dell’Immacolata, IRCCS Foundation, Rome, Italy
7Physical Medicine and Rehabilitation Unit, IRCCS, Catholic University of Sacred Heart, Rome, Italy
Corresponding Author: Massimo Mammucari ORCID iD
Address: Primary Care Unit ASL RM 1, Rome, Italy.
Received date: 11 January 2021; Accepted date: 02 March 2021; Published date: 10 March 2021
Citation: Russo D, Mammucari M, Natoli S, Maggiori E, Antonaci L, Fanelli R, Giorgio C, Catizzone AR, Troili F, Gallo A, Guglielmo C, Canzona F, Dorato D, Di Marzo R, Santini S, Gallo R, Rocchi P, Ronconi G, Ferrara PE, Guarda M. Post-Herpetic Pain Managed According to The Recommendations of the Italian Society of Mesotherapy. Asp Biomed Clin Case Rep. 2021 Mar 10;4(1):66-71.
Copyright © 2021 Russo D, Mammucari M, Natoli S, Maggiori E, Antonaci L, Fanelli R, Giorgio C, Catizzone AR, Troili F, Gallo A, Guglielmo C, Canzona F, Dorato D, Di Marzo R, Santini S, Gallo R, Rocchi P, Ronconi G, Ferrara PE, Guarda M. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.
Keywords: Post-Herpetic Pain, Mesotherapy, Intradermal Therapy, Italian Society of Mesotherapy
Drugs injected intradermally spread slowly into the underlying tissues and produce a drug-saving effect. The Italian society of mesotherapy suggested that intradermal therapy obtains analgesic effect on localized pain, with a lower risk of systemic drug interactions. We report a case of post-herpetic pain successfully treated by this technique. This case confirms that the intradermal administration technique (mesotherapy), which is based on the pathophysiology of the disorder, according to the recommendations, can contribute to the management of patients who do not tolerate standard therapies.
Herpes zoster, or shingles, is sometimes associated with acute pain, postherpetic neuralgia, and other complications [1,2]. Postherpetic neuralgia is one of the most common complications of herpes zoster, and presents with dermatomal distribution pain lasting more than 90 days, after the herpetic rash. Pain often occurs in the form of “burning”, “electric shock” and allodynia or hyperalgesia . Pain significantly compromises the quality of life and requires prolonged drug therapy [4,5]. Postherpetic pain can be managed with gabapentin, pregabalin, tricyclic antidepressants, or opiates, but adverse events may occur frequently [6-8). Systemic drugs use is limited by the patient’s age, illnesses, and coexisting treatment. Mesotherapy is a technique by which a small quantity of drug is administered in the superficial layer of the skin, through several micro-injections. The injected drug spreads slowly into the underlying tissues and generates analgesia, equivalent to systemic treatment [9,10]. Indeed, it has been hypothesized that intradermal administration allows the drug to interact with dermal structures capable of modulating some forms of pain . This technique is useful in many localized painful conditions, particularly when systemic drugs are not tolerated, or the risk of drug-drug interactions is high . We report a clinical case in order to underline the usefulness of the applied intradermal therapy according to the recommendations of the Italian mesotherapy society.
A 68 years old female, affected by chronic renal insufficiency, aortic and mitral insufficiency, and rheumatoid arthritis, assumed prednisone and methotrexate. She developed Herpes Zoster disease, all along the right T5 dermatome. The Zoster was managed with Famciclovir (1500 mg/day for ten days). One month later, the skin eruption was resolving, but the ongoing pain persisted and about 20 severe painful attacks occurred every day.
When the patient arrives at our service, she reported past severe drowsiness using pregabalin, duloxetine, and Venlafaxine, so all these drugs had been discontinued. At the time she was assuming tapentadol 100 mg/day, reporting nausea and drowsiness, so we switched to fentanyl patch 12,5 mcg/h, started micronized palmitoylethanolamide (PEA) every 12 hours, and performed a Scrambler Therapy cycle. Scrambler Therapy is an electro-analgesia used on neuropathic pain [13,14]; it was applied 45-minutes daily, for ten consecutive days. After two weeks, ongoing pain became light, but we did not obtain any improvement in the number and intensity of painful attacks. The skin healed, so we started the Lidocaine patch (700 mg 12 hours, every day) and continued fentanyl and PEA. Two weeks later, daily painful attacks decreased to 10 and pain was getting better.
Unfortunately, severe nausea raised again and fentanyl was discontinued. Moreover, the Lidocaine patch caused skin irritation, after three weeks of application. All drugs were discontinued, and pain rose immediately to the previous level. Itch became a dominant symptom. Pain levels and adverse events for every step are reported in Table-1.
The table shows situation before intradermal therapy, for every therapeutic step. Pain intensity was assessed using 0-10 Numeric Rating Scale (NRS). Neuropathic Pain was assessed using DN4 questionnaire. Pain at its worst, least and average in the last 24 hours, was assessed using the Brief Pain Inventory short form (BPI-sf)
Since the patient showed intolerance to anticonvulsants, antidepressants, opioids, and lidocaine patches, we decided to apply local intradermal therapy (Fig-1). This term refers to a series of dermal micro deposits of the drug, which results in its slow diffusion into the underlying tissues [11,12]. We implemented the first session of mesotherapy with lidocaine 10 mg/ml solution. Every session we injected about 25 mg of lidocaine, by a needle (27G, 4 mm) inclined 30° with respect to the skin surface. For each micro-puncture, a minimal amount of medication was injected (0,1-0,2 ml) to produce a small wheal, which raised slightly the surface layer of the skin. To provide a better comfort to the patients we did not inject in the painful area, but all along the superior and inferior border of the interested dermatome. Every point of injection was about 3 cm far from the previous. The patients reported moderate but bearable pain, during the needle insertion. After a week, the patient reported significant improvement, increasing in the following weeks. Only itch worse. After a week from the last session and after a month of follow up the number of pain attacks did not increase (Table-2).
The table shows parameters registered during and after the intradermal therapy
The figure shows the trend of painful crises during and after intradermal therapy
Despite the lack of data in this indication , the reported case suggests that post-herpetic neuralgia could be managed with mesotherapy. Our patient suspended all systemic drugs for adverse events. The lidocaine-based patch is a good option to reduce post-herpetic pain; however, local adverse reactions may limit its application. In this critical condition, we decided to apply lidocaine by intradermal route (mesotherapy technique). A significant reduction in the number of painful attacks was recorded, with considerable patient satisfaction. Mesotherapy has produced better results in terms of efficacy and tolerability than the patch. This result was maintained one month after the last session. In contrast, when we suspended the lidocaine patch, the patient had an immediate exacerbation of pain. The greater diffusion in the tissues underlying the site of inoculation could in part explain this difference, but mesotherapy could act not only pharmacologically: the skin could play an active role as well the reflexological effect due to the needle insertion .
In favor of this hypothesis, data have recently been recorded in favor of intradermal treatment both with respect to the oral route  and to the intravenous route . It would be interesting to compare lidocaine patch versus lidocaine mesotherapy in a randomized controlled trial.
Waiting for wider clinical studies, we recommend applying mesotherapy according to the rules of good clinical practice (Table-3) constantly updated by the Italian mesotherapy society . We strongly recommend involving the patient in the therapeutic strategy through valid informed consent . We strongly emphasize that patient satisfaction is a crucial element in pain therapy. Mesotherapy allows exploiting a further weapon useful in some forms of localized pain. The role played by local intradermal micro-injection (mesotherapy) should be better evaluated in clinical research. Even the health Authorities could suggest the application of this technique for its drug sparing effect.
The table contains basic recommendations for correct execution of intradermal therapy from the Italian society of mesotherapy [11,12,19]
DR treated and described the case, MM and DR wrote the article, all the other authors reviewed and approved the case according with the Italian mesotherapy’s recommendation before submitting it.
No external funding received to write this Case Report.
Conflicts of Interest
All authors have read and approved the final version of the manuscript. The authors have no conflicts of interest to declare.
 Weinberg JM. Herpes zoster: epidemiology, natural history, and common complications. J Am Acad Dermatol. 2007 Dec;57(6 Suppl):S130-35. [PMID: 18021864]
 Panatto D, Bragazzi NL, Rizzitelli E, Bonanni P, Boccalini S, Icardi G, Gasparini R, Amicizia D. Evaluation of the economic burden of Herpes Zoster (HZ) infection. Hum Vaccin Immunother. 2015;11(1):245-62. [PMID: 25483704]
 Johnson RW, Rice AS. Clinical practice. Postherpetic neuralgia. N Engl J Med. 2014 Oct 16;371(16):1526-33. [PMID: 25317872]
 Pickering G, Leplege A. Herpes zoster pain, postherpetic neuralgia, and quality of life in the elderly. Pain Pract. 2011 Jul-Aug;11(4):397-402. [PMID: 21199312]
 Watson PNC, Watt VR, Chipman M, Birkett N, Evans RJ. The prognosis with postherpetic neuralgia. Pain. 1991 Aug;46(2):195-99. [PMID: 1749643]
 Massengill JS, Kittredge JL. Practical considerations in the pharmacological treatment of postherpetic neuralgia for the primary care provider. J Pain Res. 2014 Mar 10;7:125-32. [PMID: 24648752]
 Johnson P, Becker L, Halpern R, Sweeney M. Real-world treatment of post-herpetic neuralgia with gabapentin or pregabalin. Clin Drug Investig. 2013 Jan;33(1):35-44. [PMID: 23179473]
 Hollingshead J, Dühmke RM, Cornblath DR. Tramadol for neuropathic pain. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD003726. Update in: Cochrane Database Syst Rev. 2017 Jun 15;6:CD003726. [PMID: 16856016]
 Mammucari M, Vellucci R, Mediati RD, et al. What is mesotherapy? Recommendations from an international consensus. Trends Med. 2014;14:1–10.
 Mammucari M, Gatti A, Maggiori S, Bartoletti CA, Sabato AF. Mesotherapy, definition, rationale and clinical role: a consensus report from the Italian Society of Mesotherapy. Eur Rev Med Pharmacol Sci. 2011 Jun;15(6):682-94. [PMID: 21796873]
 Mammucari M, Maggiori E, Antonaci L, Fanelli R, Giorgio C, Catizzone AR, Troili F, Gallo A, Guglielmo C, Russo D, Canzona F, Dorato D, Di Marzo R, Natoli S, Rocchi P, Cuguttu A, Giardini M, Gallo R, Bomprezzi A. Rational for the Intradermal Therapy (Mesotherapy) in Sport Medicine: From Hypothesis to Clinical Practise Res Inves Sports Med. 5(4). RISM.000619.2019.
 Mammucari M, Gatti A, Maggiori S, Sabato AF. Role of mesotherapy in musculoskeletal pain: opinions from the italian society of mesotherapy. Evid Based Complement Alternat Med. 2012;2012:436959. [PMID: 22654954]
 Marineo G, Iorno V, Gandini C, Moschini V, Smith TJ. Scrambler therapy may relieve chronic neuropathic pain more effectively than guideline-based drug management: results of a pilot, randomized, controlled trial. J Pain Symptom Manage. 2012 Jan;43(1):87-95. [PMID: 21763099]
 Russo D, Zoratto F, Tirocchi G, Guarda M. Scrambler therapy in the management of somatosensory signs and symptoms related to neuropathic pain: an exploratory and prospective analysis. Acta Biomed. 2018 Jun 7;89(2):180-85. [PMID: 29957749]
 Ostilio GA. First experiences and mesotherapy proposal in the treatment of Herpes zoster. J of Mesotherapy 1987; 7(2):55-56.
 Mammucari M, Maggiori E, Russo D, Giorgio C, Ronconi G, Ferrara PE, Canzona F, Antonaci L, Violo B, Vellucci R, Mediati DR, Migliore A, Massafra U, Bifarini B, Gori F, di Carlo M, Brauneis S, Paolucci T, Rocchi P, Cuguttu A, Di Marzo R, Bomprezzi A, Santini S, Giardini M, Catizzone AR, Troili F, Dorato D, Gallo A, Guglielmo C, Natoli S. Mesotherapy: From Historical Notes to Scientific Evidence and Future Prospects. ScientificWorldJournal. 2020 May 1;2020:3542848. [PMID: 32577099]
 Kocak AO. Intradermal mesotherapy versus systemic therapy in the treatment of musculoskeletal pain: A prospective randomized study. Am J Emerg Med. 2019 Nov;37(11):2061-65. [PMID: 30876777]
 Saggini R, Di Stefano A, Dodaj I, Scarcello L, Bellomo RG. Pes Anserine Bursitis in Symptomatic Osteoarthritis Patients: A Mesotherapy Treatment Study. J Altern Complement Med. 2015 Aug;21(8):480-84. [PMID: 26083769]
 Mammucari M, Maggiori E, Antonaci L, Fanelli R, Giorgio C, George F, Mouhli N, Kachlouf HR, Ksibi I, Maaoui R, Bifarini B, Ferrara PE, Gori F, Ronconi G. Intradermal therapy recommendations for standardization in localized pain management by the Italian Society of Mesotherapy. Minerva Med. 2019 Nov 11. [PMID: 31726813]
 Mammucari M, Russo D, Maggiori E, Paolucci T, Di Marzo R, Brauneis S, Bifarini B, Ronconi G, Ferrara PE, Gori F, Mediati RD, Vellucci R, Migliore A, Natoli S; Expert panel; Cancer Genome Center. Evidence based recommendations on mesotherapy: an update from the Italian society of Mesotherapy. Clin Ter. 2021 Jan-Feb;171(1):e37-e45. [PMID: 33346324]
 Mammucari M, Lazzari M, Maggiori E, Gafforio P, Tufaro G, Baffini S, Maggiori S, Palombo E, de Meo B, Sabato AF; Steering Committee of Italian Society of Mesotherapy (SIM), Italy. Role of the informed consent, from mesotherapy to opioid therapy. Eur Rev Med Pharmacol Sci. 2014;18(4):566-74. [PMID: 24615182]