Brief Overview: According to UpToDate, “Postherpetic neuralgia (PHN) is a condition characterized by focal nerve pain that occurs or persists ≥90 days after the onset of an episode of acute herpes zoster virus reactivation (shingles). In most cases of acute herpes zoster reactivation, the characteristic rash and pain resolve within 90 days of onset. In PHN, the pain persists. PHN pain localizes to the territory of the affected cranial or spinal nerve associated with the preceding acute zoster rash. PHN symptoms may be persistent and severe, leading to impairments in quality of life.”
Prevalence: According to UpToDate, “The prevalence of PHN ranges from 5 to 20 percent of patients who develop acute herpes zoster in large population studies including adults of all ages.”
Etiology: According to Cleveland Clinic, “PHN happens when shingles damages your nerve fibers. These damaged nerves send stronger pain signals to your brain than they should. This causes ongoing pain. Doctors still don’t know exactly why some people develop this condition after shingles while others don’t.”
Risk Factors:
- Age
- Female
- Severe or prolonged shingles outbreak
- Early severe acute pain during shingles
- Race – White Americans
- Immunocompromised state
- Autoimmune conditions
- Diabetes
- Tobacco use
- Genetics
Commonly Associated Conditions:
- Herpes Zoster (shingles)
- Lupus
- Chronic pain syndromes
- Depression and anxiety (secondary to chronic pain)
- Sleep disorders
Common Medications:
- Tricyclic antidepressants – amitriptyline, nortriptyline
- Gabapentin, pregabalin
- Duloxetine
- Venlafaxine
- Oxcarbazepine, carbamazepine
- Lamotrigine
- Lacosamide
- Opioids, in some cases
- Lidocaine patches
- Capsaicin cream
Common Labs, Imaging, and Tests:
- For more patients, diagnosis is made on history and exam alone and no other testing is needed
- MRI, CT
Common Symptoms:
- Pain in the same location as the preceding shingles episode
- Numbness
- Sensitive skin
Common Treatments:
- Behavioral therapy
- Acupuncture
- Epidural injections, nerve blocks
- Intradermal onabotulinumtoxinA injections
- Neuromodulation
Physical Findings:
- Per, UpToDate, “the diagnosis of PHN is made based on the presence of dermatomally restricted pain in the same location of the rash from a preceding episode of acute herpes zoster.”
- Healed shingles rash with residual skin discoloration/scarring
- Localized pain confined to a dermatome
- Allodynia (painful response to light touch)
- Hyperesthesia or numbness in affected area
- No systemic illness (unless immunocompromised)
Potential Complications and Contraindications:
- Complications:
- Chronic severe pain
- Depression, anxiety
- Insomnia
- Reduced quality of life and functional impairment
- Contraindications:
- Long-term opioid monotherapy (risk of dependence, limited efficacy)
- High-dose topical capsaicin in frail/elderly without monitoring
- TCAs in patients with cardiac arrhythmias, glaucoma, or elderly with fall risk
General Health and Lifestyle Guidance:
- Optimize sleep hygiene and stress reduction
- Maintain gentle physical activity as tolerated. Ask your healthcare provider what exercise is recommended for you.
- Use soft, loose clothing to reduce irritation of sensitive skin if needed.
- Avoid extreme temperatures (can trigger pain flares)
- Nutrition: adequate hydration, balanced diet to support nerve health
- Discuss vaccination (Shingrix) with your healthcare provider to find out if you’re eligible and/or if this would be beneficial for you
Suggested Questions to Ask Patients:
- When did your shingles rash resolve?
- How long have you had pain after the rash clearing?
- Describe your pain (burning, stabbing, constant, intermittent).
- What activities or sensations make the pain worse (clothing, touch, cold, heat)?
- How does the pain affect your sleep and daily activities?
- Have you tried medications or topical treatments before? Were they effective?
- Do you have a history of diabetes or neuropathy?
Suggested Talking Points:
- PHN is a common complication of shingles, especially in older adults.
- It happens because the virus damages the nerves, causing abnormal pain signals.
- There are several medication options (nerve pain agents, topical patches) that can help reduce pain.
- PHN is not contagious; the shingles virus is no longer active once the rash heals.
- Managing sleep, stress, and mood is an important part of treatment.
Sources:
- https://www.uptodate.com/contents/postherpetic-neuralgia?search=post%20herpetic%20neuralgia&source=search_result&selectedTitle=1~51&usage_type=default&display_rank=1
- https://my.clevelandclinic.org/health/diseases/12093-postherpetic-neuralgia#symptoms-and-causes
This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.