Feature Article

Postherpetic neuralgia: an update on management

Graham Hocking, Michael J Cousins



In the July 2002 issue of Medicine Today, Dr David Smith provided an update on the treatment of shingles. Here, the authors focus on the most feared complication, postherpetic neuralgia. This can last for years, causing physical and social disability, psychological distress, suicidal intention and increased use of the healthcare system. This article provides an update on the options for management.

Key Points

  • PHN is typically persistent burning, dysaesthetic pain in an area of previous herpes zoster infection at least three months after the acute eruption, with evidence of cutaneous healing.
  • PHN tends to be more prolonged in certain groups at risk, such as patients aged over 60 years, patients with trigeminal involvement or severe skin lesions, and patients with immunosuppression, cancer or diabetes.
  • Early aggressive treatment of herpes zoster and the associated pain is important.
  • Once PHN becomes established, tricyclic antidepressants, gabapentin, topical lignocaine and oxycodone are most likely to be beneficial.
  • Amitriptyline should be commenced in small doses at night-time, with gradual small increments made weekly until good pain relief or intolerable side effects occur. Patients should be warned of dizziness on rising due to orthostatic hypotension.
  • Patients who do not respond to treatment should be referred to a multidisciplinary pain centre where depression, coping skills and dysfunctional behaviour can be assessed as well as the need for interventional methods of pain management.