Postherpetic neuralgia is a pain that persists in some people who have had shingles. It often eases and goes over time. Medication can often ease the pain.
What is postherpetic neuralgia?
Postherpetic neuralgia (PHN) is a nerve pain (neuralgia) that persists after a shingles rash has cleared. If your pain from shingles goes but then returns at a later date, this too is called PHN.
Shingles is an infection of a nerve and causes a typical rash. It is caused by the chickenpox (varicella-zoster) virus. About 1 in 5 people have shingles at some time in their lives. Shingles can occur at any age but it is most common in people aged over 50. Most people with shingles have pain but the pain usually eases soon after the rash clears. PHN is pain that persists (or returns in some people). See the separate leaflet called Shingles (Herpes Zoster) for more details.
How common is postherpetic neuralgia?
PHN is unusual in people aged under 50 and if it does occur it tends to be mild. PHN is more likely to develop and is more likely to be severe in people aged over 60. About 1 in 4 people aged over 60 who have shingles develop PHN that lasts more than 30 days. The older you are, the more likely it is that it will occur. It is also more common in those people who have had more severe shingles.
Postherpetic neuralgia symptoms
PHN causes pain on and around the area of your skin that was affected by the shingles rash. The pain is mild or moderate in most cases. However, the pain is severe in some cases.
The pain is usually a constant burning or gnawing pain. In addition to, or instead of this, you may have sharp or stabbing pains that come and go. The affected area of skin is often very sensitive. Even slight touch may cause pain, such as the rubbing of clothes or a draught of air on the affected area. You may also have reduced sensation to touch and be itchy over the affected area.
Many people find that their sleep is disturbed. Having this pain can lead to symptoms of depression occurring in some people.
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Why does the pain persist in some people?
The symptoms of PHN can last for several months in some people. Shingles causes inflammation of the nerve. Pain can be expected whilst the rash and inflammation occur. However, it is not clear why some people continue to have pain when the inflammation has gone. It is thought that some scar tissue next to the nerve, or in the nearby part of the spinal cord, may be a factor. This may cause pain messages to be sent to the brain.
Will the pain go away?
Without treatment, PHN typically eases gradually and goes. In about 5 in 10 people with PHN, symptoms are gone by three months. However, without treatment, about 3 in 10 people with PHN still have pain after a year. Some people have a slow improvement over a long period of time. A small number of people do not have any improvement over time without any treatment.
Postherpetic neuralgia treatment?
Loose-fitting cotton clothes are best to reduce irritation of the affected area of skin. Pain may be eased by cooling the affected area with ice cubes (wrapped in a plastic bag), or by having a cool bath. Some people find that putting several layers of 'cling film' over the affected area of skin helps. This allows clothes to slide over the skin without irritating.
Commonly used traditional painkillers
You may have already tried traditional painkillers such as paracetamol that you can buy from pharmacies. However, these are unlikely to ease PHN very much in most cases.
An antidepressant medicine in the tricyclic group is a common treatment for PHN. It is not used here to treat depression. Tricyclic antidepressants ease nerve pain (neuralgia) separately to their action on depression. There are several tricyclic antidepressants. However, amitriptyline is the one commonly used for nerve pain. Pain is stopped, or greatly eased, in up to 8 in 10 cases of PHN treated with amitriptyline. Nortriptyline is the other tricyclic antidepressant that is sometimes used to treat PHN.
A tricyclic antidepressant will usually ease the pain within a few days; however, it may take 2-3 weeks. It can take several weeks before you have maximum benefit. Some people give up on their treatment too early. It is best to persevere for at least 4-6 weeks to see how well the antidepressant is working. If an antidepressant works, it is usual to take it for a further month after the pain has gone or eased. After this, the dose is gradually reduced and then stopped. You should re-start the antidepressant quickly if the pain returns.
Tricyclic antidepressants sometimes cause drowsiness. This often eases in time. To try to avoid drowsiness, a low dose is usually started at first and then built up gradually if needed. It is also usually taken at night. A dry mouth is another common side-effect. Frequent sips of water may help with this.
Anti-epileptic medicines (anticonvulsants)
An anti-epileptic medicine is an alternative to an antidepressant. For example, gabapentin, which is given to some people with PHN. Gabapentin is often used to treat epilepsy but it has also been found to ease nerve pain. An anti-epileptic medicine can stop nerve impulses causing pains separate to its action on preventing epileptic seizures. As with antidepressants, a low dose is usually started at first and built up gradually, if needed. It may take several weeks for maximum effect as the dose is gradually increased.
Strong (opiate) painkillers
Opiate painkillers are the stronger traditional painkillers - for example, codeine, morphine and related medicines. As a general rule, they are not used first-line for neuropathic pain. This is partly because there is a risk of problems of medication dependence, impaired mental functioning and other side-effects with the long-term use of opiates. Also, the medicines listed above tend to work better anyway for neuropathic pain.
Tramadol is a painkiller that is similar to opiates but has a distinct method of action that is different to other opiate painkillers. It is given to some people who have PHN.
Combinations of medicines
Sometimes both an antidepressant and an anti-epileptic medicine are taken if either alone does not work very well. Sometimes tramadol is combined with a tricyclic antidepressant or an anti-epileptic medicine. As they work in different ways, they may complement each other and have an additive effect on easing pain better than either alone.
Lidocaine patches (topical lidocaine)
Lidocaine is normally used as a local anaesthetic. Lidocaine patches contain a special gel allowing the active ingredient, lidocaine, to seep into your skin. The aim is for the lidocaine to block the pain signals coming from the nerve. Lidocaine patches are not usually advised as a 'first-line' treatment. However, they may be considered for people when other treatment options have not worked well, are unsuitable, or have caused bad side-effects. You wear a patch for 12 hours (day or night as you prefer) on or near the painful area and leave the skin open to breathe for the other 12 hours.
This is sometimes tried if the above treatments do not help, or cannot be used because of problems or side-effects. Capsaicin is thought to work by blocking nerves from sending pain messages. Capsaicin cream is applied 3-4 times a day. Wash your hands immediately after applying it. It can cause an intense burning feeling when it is applied; in particular, if it is used less than 3-4 times a day, or if it is applied just after taking a hot bath or shower. (However, this side-effect tends to ease off with regular use.) Capsaicin cream should not be applied to broken or inflamed skin. It is therefore not suitable for use during an episode of shingles. It should only be used on healthy skin which is painful due to PHN.
Treatment for itch
Some people have a severe itch with PHN. This is difficult to treat. An antihistamine taken at bedtime may help you to sleep better. It may also reduce the scratching that you may do in the night (which may then make the itch less severe the following day).
Side-effects and titrating dosages of medicines
For most of the medicines listed above it is common practice to start at a low dose at first. This may be sufficient to ease the pain but often the dose needs to be increased if the effect is not satisfactory. This is usually done gradually and is called titrating the dose. Any increase in dose may be started after a certain number of days or weeks - depending on the medicine. Your doctor will advise as to how and when to increase the dose if required; also, the maximum dose that can be taken for each particular medicine.
The aim is to find the lowest dose required to ease the pain. This is because the lower the dose, the less likely that side-effects will be troublesome. Possible side-effects vary for the different medicines used. A full list of possible side-effects can be found with information in the medicine packet. Some people don't have any side-effects and some people are only mildly troubled by side-effects that are OK to live with. However, some people are troubled quite badly by side-effects. Tell your doctor if you develop any troublesome side-effects. A switch to a different medicine may be an option if this occurs.
Can shingles and postherpetic neuralgia be prevented?
Shingles can only be prevented if you never have chickenpox, or if you have very good immunity against the chickenpox virus (that is, against the varicella-zoster virus). Most people in the UK have chickenpox as a child. However, immunity to the chickenpox virus reduces as you become older.
There is a vaccine against the varicella-zoster virus which is now offered routinely to people in the UK aged 70-79 years. The efficacy of the vaccine declines with age and so it is not recommended for people aged 80 years or older. This vaccine is the most effective way of preventing the development of PHN. It is a very effective and safe vaccine.
Further reading and references
Neuropathic pain – pharmacological management: The pharmacological management of neuropathic pain in adults in non-specialist settings; NICE Clinical Guideline (November 2013, latest update September 2020)
Lin CS, Lin YC, Lao HC, et al; Interventional Treatments for Postherpetic Neuralgia: A Systematic Review. Pain Physician. 2019 May22(3):209-228.
Saguil A, Kane S, Mercado M, et al; Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. Am Fam Physician. 2017 Nov 1596(10):656-663.