II. Epidemiology

  1. Incidence following Herpes Zoster
    1. Age over 80 years: 30%
    2. Age 60-65 years: 20%
    3. Age <50 years: Uncommon (only <20% of neuralgia cases are under age 50 years)

III. Pathophysiology

  1. Most common complication following Herpes Zoster infection
  2. Virus replication destroys Basal Ganglia

IV. Risk Factors

  1. Advanced age
  2. Female gender
  3. Severe prodrome or severe rash
  4. Severe acute pain with the acute zoster outbreak
  5. Prodromal pain prior to acute rash development
  6. Zoster Ophthalmicus
  7. Immunosuppression
  8. Diabetes Mellitus
  9. Systemic Lupus Erythematosus (SLE)

V. Symptoms

  1. Pain in dermatomal distribution persists >90 days after Herpes Zoster rash resolves
  2. Burning or electric-shock pain
  3. Hyperalgesia
  4. Allodynia

VI. Management: Topical

  1. Lidocaine 5% patch (Xylocaine, or OTC 4% patch at $2/patch)
    1. Apply (up to 3 patches/day) to affected area for 12 hours of every 24 hours (must have 12 hours free)
    2. Expensive alternatives (e.g. ZTlido 1.8% at $9/patch), but unlikely to result in better efficacy
      1. (2018) presc lett 25(11): 66
    3. Evidence of benefit is marginal
      1. Derry (2014) Cochrane Database Syst Rev (7): CD010958 [PubMed]
  2. Capsaicin cream (Zostrix) 0.075% cream
    1. Apply to affected area three to four times daily
    2. Also marginal evidence for use
      1. Derry (2012) Cochrane Database Syst Rev (9): CD010111 [PubMed]

VII. Management: Neuro-Psychiatric medications

  1. General
    1. Amitriptyline more effective than Gabapentin, but adverse effects limits tricyclic use
    2. Gnann (2002) N Engl J Med 347:340 [PubMed]
  2. Tricyclic Antidepressants
    1. Agents
      1. Amitriptyline (Elavil)
      2. Nortriptyline (Pamelor)
      3. Imipramine (Tofranil)
      4. Desipramine (Norpramin)
    2. Efficacy
      1. As effective and better tolerated than Opioids
      2. Raja (2002) Neurology 59:1015-21 [PubMed]
  3. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
    1. Cymbalta
    2. Venlafaxine
  4. Anticonvulsants
    1. Gabapentin (Neurontin) titrate up to 600-1200 mg three times daily
    2. Pregabalin (Lyrica) titrate up to 200 mg three times daily

VIII. Management: Refractory Postherpetic Neuralgia

  1. See also Chronic Pain Management
  2. Transcutaneous Electric Nerve Stimulation (TENS)
  3. Biofeedback
  4. Nerve Block
  5. Opioid Analgesics
  6. Intrathecal Methylprednisolone 60 mg at L2-L3
    1. Good to excellent pain relief in refractory cases
    2. Relief persists longer than 2 years
    3. References
      1. Kotani (2000) N Engl J Med 343:1514-9 [PubMed]

IX. Course

  1. Typical duration: 30 days to 6 months
  2. Some cases may persist years

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Related Studies

Ontology: Postherpetic neuralgia (C0032768)

Definition (MSH) Pain in nerves, frequently involving facial SKIN, resulting from the activation the latent varicella-zoster virus (HERPESVIRUS 3, HUMAN). The two forms of the condition preceding the pain are HERPES ZOSTER OTICUS; and HERPES ZOSTER OPHTHALMICUS. Following the healing of the rashes and blisters, the pain sometimes persists.
Concepts Disease or Syndrome (T047)
MSH D051474
ICD10 G53.0
SnomedCT 186516001, 186522005, 154327006, 2177002
Italian Nevralgia post-erpetica, Nevralgia posterpetica
English Postzoster neuralgia, postherpetic neuralgia (diagnosis), postherpetic neuralgia, neuralgia postherpetic, Post-herpetic neuralgia, PHN, Neuralgia, Postherpetic [Disease/Finding], phn, post herpetic neuralgia, Neuralgia;post-herpetic, herpetic neuralgia post, neuralgias postherpetic, Post-herpetic Neuralgia, Post-herpetic neuralgia (disorder), Post herpetic neuralgia, PHN - Post-herpetic neuralgia, Post-zoster neuralgia, Postherpetic neuralgia (disorder), neuralgia; postherpetic (etiology), neuralgia; postherpetic (manifestation), postherpetic neuralgia (etiology), postherpetic neuralgia (manifestation), postherpetic; neuralgia (etiology), postherpetic; neuralgia (manifestation), Postherpetic neuralgia, Neuralgia, Postherpetic, Postherpetic Neuralgia, post-herpetic neuralgia
French Névralgie postherpétique (PHN), Névralgie post-herpétique
German PHN, Neuralgie nach Zoster, postherpetische Neuralgie, Neuralgia postherpetica, Neuralgie, postherpetische, Postherpetische Neuralgie
Spanish NPH, neuralgia posherpética (trastorno), neuralgia posherpética, neuralgia postherpética (trastorno), neuralgia postherpética, Neuralgia postherpética, Neuralgia Posherpética
Swedish Neuralgi, postherpetisk
Japanese ヘルペスゴシンケイツウ, ヘルペスアトシンケイツウ, 神経痛-帯状疱疹後, 疼痛-帯状疱疹後, ヘルペス後神経痛, 帯状疱疹後神経痛, 帯状疱疹痛
Czech neuralgie postherpetická, Postherpetická neuralgie, PHN
Finnish Postherpeettinen neuralgia
Korean 대상포진후 신경통
Polish Nerwoból półpaścowy, Neuralgia po półpaścu
Hungarian Postherpeszes neuralgia, Postherpeses neuralgia
Norwegian Neuralgia postherpetica, Postherpetisk nevralgi
Dutch neuralgie; postherpetisch, postherpetisch; neuralgie, Neuralgie na herpes zoster, postherpetische neuralgie
Portuguese Nevralgia pós-herpética, Neuralgia Pós-Herpética