Pharmacology and therapeutics

Jaipur block in postherpetic neuralgia

Rishi Bhargava, MD, MNAMS, MSSVD, Sudha Bhargava, MD, Kailash N. Haldia, MD, and
Puneet Bhargava, MBBS

From the Departments of Abstract

Dermatology and Anesthesia, SMS Background Postherpetic neuralgia, a common sequele to herpes zoster infection, is a
Medical College, Jaipur, India
chronic debilitating problem. The available therapeutic modalities are usually ineffective.
Methods A total of 3960 patients (1326 women and 2634 men; age group, 21–84 years),
Correspondence
Rishi Bhargava, MD, MNAMS, MSSVD with postherpetic neuralgia as the presenting complaint and with pain lasting from 2
C-32, Peeyush Path months to 5 years, were treated with Jaipur block, consisting of local subcutaneous
Bapu Nagar infiltration of 2% xylocaine, 0.5% bupivacaine, and 4 mg/mL dexamethasone solution.
Jaipur 302 015
Patients were followed up at six-weekly intervals with subsequent injections given in non-
India
responders.
Results Twenty eight per cent of patients obtained complete relief from pain after a
single injection, another 57% after a second injection, and 11% after a third injection; 4%
of patients did not respond to treatment. The non-responders were either old (over 60
years) or had pain lasting for more than 2 years. The response to therapy was similar in
both sexes. There were 31 left-handed patients in this study. Pain was less severe in left-
handed patients and they obtained complete relief after a single injection. Side-effects
including giddiness and sweating were seen, occasionally, in a few patients.
Conclusions Ninety six per cent of patients obtained complete relief after the block with
a follow-up of up to 19 years.

Herpes zoster infection is caused by the reactivation of with herpes zoster have postherpetic neuralgia.2 The patho-
dormant varicella-zoster virus in the dorsal root ganglion genesis of pain involves inflammation in the skin and dorsal
due to the waning of cellular immunity. It presents as root ganglion, altered normal sensory functions with pain
grouped vesicular lesions on an erythematous base unilater- provoked by trivial stimuli such as touch and temperature
ally and involving one or two adjacent dermatomes, with (allodynia), altered central nervous system signal pro-
thoracic, cervical, and ophthalmic involvement most com- cessing, low neural activation threshold, and unprovoked
mon.1 The lesions pustulate and crust in 7 to 10 days, but peripheral neuronal discharge.1,5,6 Postherpetic neuralgia
may take months to heal, often with hypoesthetic scars, presents as a chronic problem to both the patient and the
pigmented spots, and pain.1 The annual incidence of herpes physician. Various treatment modalities to relieve and
zoster varies with the age and immune status of the treat this intractable pain include local capsaicin cream,
individual from a range of 1.6 to 4 cases/1000 healthy anesthetic drugs such as lidocaine, procaine, and mepiva-
people under the age of 20 years to 4.5 to 11/1000 old caine applied topically, or injected locally or intravenously,
people (80 years or over).2,3 Herpes zoster is more common benzydamine cream, tricyclic antidepressant drugs, anticon-
in adults with human immunodeficiency virus (HIV) infec- vulsants such as phenytoin, carbamazepine, and valproic
tion and malignancy and 50 to 100 times higher in children acid, corticosteroids with or without acyclovir, neuro-
with leukemia than in healthy individuals of the same age.1 surgical procedures such as anterolateral cordotomy,
Postherpetic neuralgia has been defined as the presence electrical stimulation of thalamus and spinal cord, electro-
of pain more than 1 month after the onset of the eruption coagulation of well-defined areas of dorsal root, and coun-
of herpes zoster.4 The condition has also been defined as ter-irritation.1,7–13 None of these procedures produce a
pain persisting after 6 weeks or after 6 months of the onset satisfactory result due to the complexity of the pathogenesis
of the eruption of herpes zoster or after crusting of the of postherpetic neuralgia. We have developed the technique
skin lesions.1 It is believed that about 10–70% of patients of Jaipur block for the treatment of postherpetic neuralgia. 465

© 1998 Blackwell Science Ltd International Journal of Dermatology 1998, 37, 465–468
466 Pharmacology and therapeutics Jaipur block in postherpetic neuralgia Bhargava et al.

We have treated 3960 patients over a period of 19 years Table 1 Age group of patients affected with postherpetic
with very good results. neuralgia

Age group (years) Patients

Materials and methods (range, 21–84 years)
No. %
The total number of patients treated was 3960 over a study
period of 19 years (1977–1996). The materials used were 2% 21–30 17 0.42
xylocaine (30 mL), 0.5% bupivacaine (20 mL), and 31–40 439 11.08
dexamethasone 4 mg/mL (2 mL). 41–50 827 20.88
51–60 619 15.63
Xylocaine (30 mL) was mixed with dexamethasone (1 mL)
61–70 1107 27.95
and kept in one vial. Bupivacaine (20 mL) was mixed with
71–80 812 20.50
dexamethasone (1 mL) and kept in a separate vial. The 81–90 139 3.51
patients were evaluated with regard to underlying malignancy,
Total 3960 100.00
metabolic disorders, myeloproliferative disorders, and HIV
infection wherever applicable.
The affected area receiving the injection was selected, with
special consideration given to the most painful region, healed
scars, and pigmented spots. About 2.5 mL of solution was Table 2 Duration of postherpetic neuralgia
drawn from each vial in a syringe. There was no precipitation
in the solution. After pinching the skin at the pigmented spot or Duration of pain Patients
at the site of a scar, 4–5 mL of clear solution was injected (2 months to 5 years)
No. %
subcutaneously and blindly at each site of nerve damage (4–10
sites in each patient). 0–6 months 1861 46.99
Patients were followed up at six-weekly intervals. If pain was 6 months to 1 year 871 21.99
not relieved with a single injection, further injections were given 1–2 years 673 16.99
2–3 years 435 10.98
at following visits. A record of patients was maintained with a
3–4 years 79 1.99
follow-up of up to 19 years. Jaipur block was used only in . 4 years 41 1.03
those patients who were resistant to other modalities of
Total 3960 100.00
treatment. This was the only method of therapy used in this
study.

Results
The total number of patients treated with Jaipur block was
3960 (1326 women and 2634 men). There was no evidence
of any underlying malignancy, metabolic disorders, or HIV
infection in these patients. The maximum number of
patients (48%) belonged to the 60–80-year age group
(range, 21–84 years) (Table 1). The pain was described
variously as shooting, cutting, boring, insect crawling,
aching, stinging, and dull burning; 47% of patients had
pain lasting for 0–6 months (range, 2 months to 5 years)
Table 2), followed by 22% for 6 months to 1 year. The
thoracic segment was involved in 57% of patients, the
trigeminal nerve in 19%, and the abdominal segment in Figure 1 Segmental involvement in postherpetic neuralgia
17% (Fig. 1). After the first injection, 28% of patients
obtained complete relief; another 57% of patients obtained
relief after the second injection and 11% after the third
injection. Only 4% of patients were resistant to treatment study. Postherpetic neuralgia pain was less severe in these
(Fig. 2). The non-responders were either old (over 60 years) patients, and they obtained complete relief after the first
or had pain lasting for more than 2 years (Tables 3 and injection. Negligible side-effects were observed, except for
4). Men and women responded equally. It was interesting sweating and giddiness in a few patients. There was no
to note that there were 31 left-handed patients in this recurrence on follow-up of the patients.

International Journal of Dermatology 1998, 37, 465–468 © 1998 Blackwell Science Ltd
Bhargava et al. Jaipur block in postherpetic neuralgia Pharmacology and therapeutics 467

other mild analgesic drugs are commonly used in posther-

petic neuralgia, neuropathic pain is less responsive to them.14
In a large, controlled trial of capsaicin cream involving 143
patients with postherpetic neuralgia of at least 6 months
duration, there was only a 21% reduction in pain score after
4 weeks.15 Five trials with tricyclic antidepressant drugs
have shown an improvement in 47–67% of patients with
postherpetic neuralgia.16–20 Anticonvulsants reduce the lan-
cinating component of neuropathic pain,21 but the benefit
has been shown to be small in uncontrolled trials.22 The use
of antiviral drugs alone, or with corticosteroids, is mainly
for the prevention of postherpetic neuralgia.1 There are many
Figure 2 Relief from pain of postherpetic neuralgia following anecdotal reports of the efficacy of the infiltration of the skin,
Jaipur block peripheral nerves, or paravertebral or epidural spaces with
local anesthetic drugs in patients with herpes zoster, but
controlled studies are lacking with regard to their efficacy in
Table 3 Age vs. failure (%) the treatment and prevention of postherpetic neuralgia.23–27
A large, retrospective study has suggested that any benefits
Age group (years) Patient no. Failure no. Failure (%) of somatic-nerve blocks are limited to the first 2 months
(range, 21–84 years)
of pain.27
21–30 17 1 5.80 Our study is probably the largest series of patients
31–40 439 7 1.59 treated. The very high cure rate is illustrated by the fact
41–50 827 17 2.05 that 96% of patients obtained complete relief with Jaipur
51–60 619 12 1.93
block with a follow-up of up to 19 years. The side-effects
61–70 1107 63 5.69
71–80 812 42 5.17
were negligible, with giddiness and sweating seen in a few
81–90 139 17 12.23 patients. Battcock et al.28 have shown that left-handed
subjects are less likely to develop herpes zoster, and that
Total 3960 159
this may be due to a more efficient immune system. We
also found that postherpetic neuralgia was less severe in
left-handed patients; they obtained complete relief after a
Table 4 Length of disease vs. failure (%) single injection.

Length of disease Patient no. Failure no. Failure (%)

(duration of pain)
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Mouse models for pemphigus vulgaris

The balding mutation (original gene symbol: bal, new gene symbol; Dsg3bal) arose spontan-
eously in a mouse colony at The Jackson Laboratory and was first reported 20 years ago;
however, the mutant locus was only recently mapped to mouse Chromosome 18. Another
alopecia mutation (now designated Dsg3bal-Pas) arose spontaneously at the Institut Pasteur
in 1985. It was made congenic on the 129/Sv background and mapped independently to
mouse Chromosome 18. Based on the gene location and similarity of the clinical and
histologic phenotypes the two mutations (Dsg3bal and Dsg3bal–Pas) were crossed to yield
affected offspring which confirmed that they were alleles. A targeted null mutation of the
desmoglein 3 gene (Dsgtm/Stan) is recessive. A third spontaneous mutation arose in C3H/HeJ
mice at The Jackson Laboratory and was designated Dsg3bal-2J. This mutation is extinct.

From Sundberg JP, Shultz LD, King LE, Montagutelli X. Mouse models for pemphigus
vulgaris. Comp. Path Bull 1998; XXX: 3.

International Journal of Dermatology 1998, 37, 465–468 © 1998 Blackwell Science Ltd