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Corticosteroids and postherpetic neuralgia
Volume 20 Number 3 March 1989
REFERENCES 1. ReynoldsP, Austin D, Thomas J. Familial and occapational risks associated with malignant melanoma of the skin. Am J Epidemiol 1982;116:570. 2. Beral V, Evans S, Shaw H, Milton G. Cutaneous factors related to the risk of malignant melanoma. Br J Dermatol 1983;109:165-72. 3. Hohnan CDJ, Armstrong BK. Pigmentary traits, ethnic origin, benign nevi, and family history as risk factors for cutaneous malignant melanoma. J Natl Cancer Inst 1984;72:257-66. 4. Green A, MacLennan R, Siskind V. Common acquired naevi and the risk of malignant melanoma. Int J Cancer 1985;35:297-300. 5. Elwood JM, Williamson C, Stapleton PJ. Malignant melanomain relation to moles, pigmentation,and exposure to fluorescent and other lighting sources. Br J Cancer 1986;53:65-74. 6. Nordlund J J, Kirk-woodJ, Forget BM, et al. Demographic study of clinicallyatypical (dysplastic)nevi in patientswith melanoma and comparison subjects. Cancer Res 1985; 45:1855-61. 7. Swerdlow AJ, English J, MacKie RM, et al. Benign melanocyticnaevi as a risk factor for malignantmelanoma. Br Med J 1986;292:1555-9.
Cortieosteroids and postherpetic neuralgia To the Editor: I would like to congratulate Post and Philbrick on their excellent article, "Do Costicosteroids Prevent Postherpetic Neuralgia?" (J AM ACADDERMA"rOE 1988;18:605-10). Correctly, they state that the methodologic difficulties in the individual studies that have attempted to answer this question ~-4 make it difficult to ascertain whether the practice is effective. At least two additional methodologic problems should be addressed. First, no mention is made of checking patient compliance in any of these studies. Second, one of the studies was apparently an outpatient study,~whereas the other three included patients admitted to the hospital for treatment, which may also help to explain the divergent treatment outcomes. There are, however, several problems associated with a comparison approach such as this. At worst, an erroneous conclusion can be made on the basis of the reviewer's bias; at best, conclusions are difficult to make because of the different methodologies employed. Indeed, there are even cases in the social science literature of researchers who, in reviewing the same articles, come to totally opposite conclusions:s Clearly, further research is needed. One approach is to repeat the studies, adhering rigorously to the criteria stipulated by Post and Philbrick. This is currently being done in a multi-center study sponsored by the National Institutes of Health (NIH), which is investigating the effect of the early use of corticosteroids and/or acyclovir in herpes zoster infections on the subsequent development of postherpetic neuralgia.
Correspondence 523 Another approach is to do a meta-analysis of the existing studies, that is, "a statistical analysis of a large collection of results from individual studies for the purpose of integrating the results. ''6 The basic tenet of the technique is that it is impossible to conduct the perfect research study: Thus, by combining studies, even those with flaws, more useful information can be obtained than by comparing the results of the contradictory studies alone. Moreover, by the incorporation of studies with various flaws the faults should logically cancel themselves out: In a meta-analysis of these four randomized clinical controlled studies (Lycka, Int J Derm, in press), my results were similar to those of the study by Esman et al.4 Specifically, it was found that systemic corticosteroids cause a reduction in the number of patients with postherpetic neuralgia 6 and 12 weeks after the onset of the acute zoster, but by 24 weeks the reduction was negligible. Thus, pending the conclusion of the NIH-sponsored study, it appears that corticosteroids do affect the natural history of postherpetic neuralgia. Because postherpetic neuralgia is so devastating when it occurs, it would be prudent to continue its use in highly selected groups of patients with acute herpes zoster who are at considerable risk for the development of this complication and who are at low risk for dissemination.
Barry A. S. Lycka, MD University of Minnesota Hospital Minneapolis, M N 55455-0392
REFERENCES 1. Eaglestein WH, Katz R, Brown JA. The effects of early corticosteroidtherapy on the skin eruption of herpes zoster. JAMA 1970;211:1681-3. 2. Keckes K, Basheer AM. Do corticosteroicls prevent postherpetic neuralgia? Br J Dermatol 1980;102:551-5. 3. Clemmenson OJ, Anderson KE. ACTH versus prednisone and placebo in herpes zoster treatment. Clin Exp Dermatol 1984;9:557-63. 4. Esman V, Kroon S, Peterslund NA, et aL Prednisone does not prevent postherpetic neuralgia. Lancet 1987;2:126-9, 5. Rosenthal R. Meta-analytie procedures for social science research. BeverlyHills, CA: Sage, 1984. 6. Glass GV, McGaw B, Smith ML. Meta-analysis in social research. BeverlyHills, CA: Sage, 1981. 7. Glass GV, Smith ML. Reply to Eysenck. Am Psyehol 1978;33:517-9.
Reply To the Editor: I would like to thank Drs. Post and Philbrick for their scientific commentary, "Do Corticosteroids Prevent Postherpetic Neuralgia?" (J AM AcAo DERMATOL 1988;18:605-10). It was thoroughly researched and well written.
REFERENCES 1. ReynoldsP, Austin D, Thomas J. Familial and occapational risks associated with malignant melanoma of the skin. Am J Epidemiol 1982;116:570. 2. Beral V, Evans S, Shaw H, Milton G. Cutaneous factors related to the risk of malignant melanoma. Br J Dermatol 1983;109:165-72. 3. Hohnan CDJ, Armstrong BK. Pigmentary traits, ethnic origin, benign nevi, and family history as risk factors for cutaneous malignant melanoma. J Natl Cancer Inst 1984;72:257-66. 4. Green A, MacLennan R, Siskind V. Common acquired naevi and the risk of malignant melanoma. Int J Cancer 1985;35:297-300. 5. Elwood JM, Williamson C, Stapleton PJ. Malignant melanomain relation to moles, pigmentation,and exposure to fluorescent and other lighting sources. Br J Cancer 1986;53:65-74. 6. Nordlund J J, Kirk-woodJ, Forget BM, et al. Demographic study of clinicallyatypical (dysplastic)nevi in patientswith melanoma and comparison subjects. Cancer Res 1985; 45:1855-61. 7. Swerdlow AJ, English J, MacKie RM, et al. Benign melanocyticnaevi as a risk factor for malignantmelanoma. Br Med J 1986;292:1555-9.
Cortieosteroids and postherpetic neuralgia To the Editor: I would like to congratulate Post and Philbrick on their excellent article, "Do Costicosteroids Prevent Postherpetic Neuralgia?" (J AM ACADDERMA"rOE 1988;18:605-10). Correctly, they state that the methodologic difficulties in the individual studies that have attempted to answer this question ~-4 make it difficult to ascertain whether the practice is effective. At least two additional methodologic problems should be addressed. First, no mention is made of checking patient compliance in any of these studies. Second, one of the studies was apparently an outpatient study,~whereas the other three included patients admitted to the hospital for treatment, which may also help to explain the divergent treatment outcomes. There are, however, several problems associated with a comparison approach such as this. At worst, an erroneous conclusion can be made on the basis of the reviewer's bias; at best, conclusions are difficult to make because of the different methodologies employed. Indeed, there are even cases in the social science literature of researchers who, in reviewing the same articles, come to totally opposite conclusions:s Clearly, further research is needed. One approach is to repeat the studies, adhering rigorously to the criteria stipulated by Post and Philbrick. This is currently being done in a multi-center study sponsored by the National Institutes of Health (NIH), which is investigating the effect of the early use of corticosteroids and/or acyclovir in herpes zoster infections on the subsequent development of postherpetic neuralgia.
Correspondence 523 Another approach is to do a meta-analysis of the existing studies, that is, "a statistical analysis of a large collection of results from individual studies for the purpose of integrating the results. ''6 The basic tenet of the technique is that it is impossible to conduct the perfect research study: Thus, by combining studies, even those with flaws, more useful information can be obtained than by comparing the results of the contradictory studies alone. Moreover, by the incorporation of studies with various flaws the faults should logically cancel themselves out: In a meta-analysis of these four randomized clinical controlled studies (Lycka, Int J Derm, in press), my results were similar to those of the study by Esman et al.4 Specifically, it was found that systemic corticosteroids cause a reduction in the number of patients with postherpetic neuralgia 6 and 12 weeks after the onset of the acute zoster, but by 24 weeks the reduction was negligible. Thus, pending the conclusion of the NIH-sponsored study, it appears that corticosteroids do affect the natural history of postherpetic neuralgia. Because postherpetic neuralgia is so devastating when it occurs, it would be prudent to continue its use in highly selected groups of patients with acute herpes zoster who are at considerable risk for the development of this complication and who are at low risk for dissemination.
Barry A. S. Lycka, MD University of Minnesota Hospital Minneapolis, M N 55455-0392
REFERENCES 1. Eaglestein WH, Katz R, Brown JA. The effects of early corticosteroidtherapy on the skin eruption of herpes zoster. JAMA 1970;211:1681-3. 2. Keckes K, Basheer AM. Do corticosteroicls prevent postherpetic neuralgia? Br J Dermatol 1980;102:551-5. 3. Clemmenson OJ, Anderson KE. ACTH versus prednisone and placebo in herpes zoster treatment. Clin Exp Dermatol 1984;9:557-63. 4. Esman V, Kroon S, Peterslund NA, et aL Prednisone does not prevent postherpetic neuralgia. Lancet 1987;2:126-9, 5. Rosenthal R. Meta-analytie procedures for social science research. BeverlyHills, CA: Sage, 1984. 6. Glass GV, McGaw B, Smith ML. Meta-analysis in social research. BeverlyHills, CA: Sage, 1981. 7. Glass GV, Smith ML. Reply to Eysenck. Am Psyehol 1978;33:517-9.
Reply To the Editor: I would like to thank Drs. Post and Philbrick for their scientific commentary, "Do Corticosteroids Prevent Postherpetic Neuralgia?" (J AM AcAo DERMATOL 1988;18:605-10). It was thoroughly researched and well written.