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Postherpetic Neuralgia
Aka: Postherpetic Neuralgia, Post-herpetic Neuralgia
- See Also
- Herpes Zoster
- Zoster Ophthalmicus
- Epidemiology
- Incidence following Herpes Zoster
- Age over 80 years: 30%
- Age 60-65 years: 20%
- Age <50 years: Uncommon (only <20% of neuralgia cases are under age 50 years)
- Pathophysiology
- Most common complication following Herpes Zoster infection
- Virus replication destroys Basal Ganglia
- Risk Factors
- Advanced age
- Female gender
- Severe prodrome or severe rash
- Severe acute pain with the acute zoster outbreak
- Prodromal pain prior to acute rash development
- Zoster Ophthalmicus
- Immunosuppression
- Diabetes Mellitus
- Systemic Lupus Erythematosus (SLE)
- Symptoms
- Pain in dermatomal distribution persists >90 days after Herpes Zoster rash resolves
- Burning or electric-shock pain
- Hyperalgesia
- Allodynia
- Management: Topical
- Lidocaine 5% patch (Xylocaine, or OTC 4% patch at $2/patch)
- Apply (up to 3 patches/day) to affected area for 12 hours of every 24 hours (must have 12 hours free)
- Expensive alternatives (e.g. ZTlido 1.8% at $9/patch), but unlikely to result in better efficacy
- (2018) presc lett 25(11): 66
- Evidence of benefit is marginal
- Derry (2014) Cochrane Database Syst Rev (7): CD010958 [PubMed]
- Capsaicin cream (Zostrix) 0.075% cream
- Apply to affected area three to four times daily
- Also marginal evidence for use
- Derry (2012) Cochrane Database Syst Rev (9): CD010111 [PubMed]
- Management: Neuro-Psychiatric medications
- General
- Amitriptyline more effective than Gabapentin, but adverse effects limits tricyclic use
- Gnann (2002) N Engl J Med 347:340 [PubMed]
- Tricyclic Antidepressants
- Agents
- Amitriptyline (Elavil)
- Nortriptyline (Pamelor)
- Imipramine (Tofranil)
- Desipramine (Norpramin)
- Efficacy
- As effective and better tolerated than Opioids
- Raja (2002) Neurology 59:1015-21 [PubMed]
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)
- Cymbalta
- Venlafaxine
- Anticonvulsants
- Gabapentin (Neurontin) titrate up to 600-1200 mg three times daily
- Pregabalin (Lyrica) titrate up to 200 mg three times daily
- Management: Refractory Postherpetic Neuralgia
- See also Chronic Pain Management
- Transcutaneous Electric Nerve Stimulation (TENS)
- Biofeedback
- Nerve Block
- Opioid Analgesics
- Intrathecal Methylprednisolone 60 mg at L2-L3
- Good to excellent pain relief in refractory cases
- Relief persists longer than 2 years
- References
- Kotani (2000) N Engl J Med 343:1514-9 [PubMed]
- Course
- Typical duration: 30 days to 6 months
- Some cases may persist years
- Prevention
- See Herpes Zoster
- Herpes Zoster Vaccine (Zostavax)
- References
- Fashner (2011) Am Fam Physician 83(12): 1432-7 [PubMed]
- Kost (1996) N Engl J Med 335:32-42 [PubMed]
- Rowbotham (1998) JAMA 28:1837-42 [PubMed]
- Saguil (2017) Am Fam Physician 96(10): 656-63 [PubMed]
- Stankus (2000) Am Fam Physician 61(8):2437-44 [PubMed]