The Clinton Herald, Clinton, Iowa

November 18, 2013

Cut the nerve end, end the pain?

Dr. Keith Roach
Special to the Herald

CLINTON — DEAR DR. ROACH: I am 85 and in fairly good health, but I am in my ninth year of extremely painful post-herpetic neuralgia. Instead of diminishing, the pain is increasing. It could be that the gabapentin (600 mg, three times daily) is wearing off. I tried Lyrica, but stopped when it hurt my eyes. The pain can be excruciating, even from the touch of a shirt. A relative suggested cutting the affected nerve. What would you recommend? — F.S.

ANSWER: Post-herpetic neuralgia is a syndrome of pain due to inflammation of the nerves after an infection with herpes zoster. The older you are, the more likely you are to get this complication, and the longer the pain tends to last — but nine years is much longer than normal.

Treatment for post-herpetic neuralgia is often with several medications. Gabapentin (Neurontin) is one, but the effective dose is sometimes quite high, as high as 1,200 mg three times daily. Many people get very fatigued at that high a dose. A much older medication, nortriptylene, is more effective in some people and may be worth a try.

Capsaicin cream provides relief for many people, although it can cause some burning when first applied. I recommend starting with the regular, not high-potency, strength.

Unfortunately, surgery — at any level, from the end of the nerve to the brain — has not been consistently effective and carries the risk of permanent nerve damage. Fortunately, this complication can be largely prevented with the use of the shingles vaccine, which most people over 60 should get, even if they have had shingles before.

DEAR DR. ROACH: My friend had skin cancer on her nose, and her doctor treated it by cutting it off. My friend said she has had many, and her doctor always cuts them off. I had skin cancer about 20 years ago. My doctor gave me Efudex cream, which worked on my skin cancers, but did nothing to my healthy skin. Why in the world aren’t today’s skin-cancer doctors prescribing Efudex? It’s so great. I think not prescribing it for my friend today is a form of malpractice. What do you think? — D.P.

ANSWER: I don’t have enough information to say what the best treatment is for your friend. For the most common skin cancer, basal cell carcinoma, both surgery and 5-fluorouracil (Efudex) are very effective, around 95 percent effective or more. However, authorities recommend particular care with Efudex around the eyes, lips and nose, and in these cases surgery may be both more effective and better tolerated. If the cancer was a squamous cell cancer, Efudex is sometimes used, but surgery tends to be preferred.

I would be very circumspect in using the term “malpractice.” In a situation where there are two very effective treatments, either one is reasonable, and there may be factors you and I don’t know about that her dermatologist or surgeon does.

DEAR DR. ROACH: Would someone who has a gluten intolerance be able to use psyllium products (Metamucil) without any problems? What I really want to know is, does psyllium have gluten, since it comes from wheat husks? Thank you for your answer. — S.S.

ANSWER: Psyllium is gluten-free. It is made from the husks of the Plantago plant, not wheat. Psyllium is an excellent source of fiber, but should be started at a low dose and gradually increased to avoid bloating.