The most common sites associated with postherpetic neuralgia are the cranial nerve and cervical and thoracic spine most predominantly the fourth to sixth dermatomes. The pain may range from sharp, stabbing to burning. Many patients also complain of allodynia. The other sensory modalities are usually affected within the dermatome, with diminished vibration, tactile and thermal sensation. There are usually scars along the affected dermatome, making the diagnosis less complicated [6].

• Severe Pain

  Advanced age and severe initial pain intensity were predictive factors of PHN development. Prolonged catheterization resulting from weak response to treatment strongly suggested progression to PHN. [ncbi.nlm.nih.gov]

  The shingles rash is accompanied with, or may be preceded by, acute, often severe pain; the persistence of neuropathic pain beyond three months is described as postherpetic neuralgia (PHN). [medicinetoday.com.au]

• Weakness

  Prolonged catheterization resulting from weak response to treatment strongly suggested progression to PHN. [ncbi.nlm.nih.gov]

  Symptoms may include: Burning or sharp pain Itching and numbness Muscle weakness Pain management specialists diagnose postherpetic neuralgia by conducting: Physical exam NEXT: Treatment Options › Top Honors [mdmercy.com]

  Shingles are more likely to occur among older adults, as well individuals with a weak immune system. 4-6 Postherpetic Neuralgia Neuralgia is the pain that occurs when a nerve becomes irritated or inflamed. [emsworld.com]

  Postherpetic neuralgia causes several characteristic symptoms, including burning or jabbing pain, heightened sensitivity to light touch, numbness, itching and muscle weakness or paralysis. [livestrong.com]

• Falling

  RESULTS: Patients treated with 5% lidocaine had less trouble falling asleep, used less sleep medication, had fewer awakenings due to pain at night or in the morning and their perception of quality of life was improved. [ncbi.nlm.nih.gov]

  The blisters of shingles will crust over and fall off on their own, and it's important to avoid picking at the blisters to prevent the development of a secondary skin infection at the inflamed site. [medicinenet.com]

  While it’s tempting to want to stay inside from the first cool breeze of fall to the last spring shower, or maybe move closer to the equator, it’s not always realistic. [mainespinenerve.com]

  Talk to your doctor to find out more if you fall into this group. Gender: Women seem to get it more than men. Early symptoms: People who have numbness, tingling, or itching before a shingles rash even appears tend to get the lingering pain later. [webmd.com]

• Burning Pain

  The deep burning pain and extreme skin sensitivity can greatly impact the quality of your life. We are conducting a research study of a once daily, investigational from of pregabalin for the pain of PHN YOU MAY QUALIFY FOR THIS ... [centerwatch.com]

  The burning pain and hyperesthesia resolved after the 16th day of amitriptyline use, 75 mg/day. A trial off amitriptyline 6 mo later resulted in recurrence of pain, and amitriptyline was restarted with good pain control. [ncbi.nlm.nih.gov]

• Malaise

  The initial symptoms are rash, fever, and malaise. Within a few days, a rash appears; the skin lesions usually start on the trunk, then spread to the arms and legs. The lesions crust over 1–2 weeks, and the rash usually resolves over 3–5 weeks. [n.neurology.org]

  Symptoms during this “initial phase” include: Fever Headache Malaise Itching Burning pain accompanied with itching and oversensitivity in a distinct and limited area Pins and needles (paresthesias), tingling, numbness in a distinct and limited area Painful [ainsworthinstitute.com]

  The remaining 12 patients began receiving oral valacyclovir after 14 days of IV acyclovir; 10 patients completed the 30-day course, and 2 stopped early (one because of unexplained dyspnea and the other because of nausea, fatigue, and malaise). [jamanetwork.com]

  The earliest symptoms of shingles, which include headache, fever, and malaise, are nonspecific, and may result in an incorrect diagnosis. [en.wikipedia.org]

  The patient may feel unwell with malaise, myalgia, headache and fever but these symptoms may abate as the eruption appears. In the pre-eruptive phase the skin may be tender but there are no lesions to see. There may be lymphadenopathy. [patient.info]

• Loss of Appetite

  Postherpetic neuralgia may also result in: tiredness loss of appetite inability to perform your usual daily tasks because of the pain. How is it diagnosed? There are no special tests for postherpetic neuralgia. [kpjampang.com]

• Xerostomia

  Xerostomia is dry mouth caused by reduced or absent flow of saliva. [merck.com]

• Muscle Weakness

  Symptoms may include: Burning or sharp pain Itching and numbness Muscle weakness Pain management specialists diagnose postherpetic neuralgia by conducting: Physical exam NEXT: Treatment Options › Top Honors [mdmercy.com]

  Postherpetic neuralgia causes several characteristic symptoms, including burning or jabbing pain, heightened sensitivity to light touch, numbness, itching and muscle weakness or paralysis. [livestrong.com]

  Symptoms of postherpetic neuralgia include: Itching Extreme sensitivity to touch Burning, shooting pain Headaches Numbness Muscle weakness Sensitivity to changes in temperature Burning and stinging, as well as increased sensitivity, are the most noticeable [centraltexaspaincenter.com]

  In rare cases,where if the nerves involved also control muscle movement, the patient might also experience muscle weakness, tremor or paralysis Treatment The conventional treatment is directed at pain control while waiting for the condition to resolve [askdrshah.com]

• Blister

  blisters often leave no scars. [ninds.nih.gov]

  Usually the diagnosis of herpes zoster is easily made when a painful blistering rash arises that has dermatomal distribution (ie, along the pathway of a cutaneous nerve). [dermnetnz.org]

  The painful area usually develops a rash, which forms blisters that break open, crust over, and heal. For most patients, the pain of shingles slowly disappears over a few weeks once the blisters have healed. [uspharmacist.com]

  This virus may become active when the immunity of the individual reduces or during convalescence after a major illness, resulting in blisters on the skin, known as shingles. [askdrshah.com]

  Shingles appear as a rash, patch or line of painful blisters which arise on the skin over a nerve in the shape of a band. This band follows the distribution of a specific nerve where the virus has been living before it spreads to the skin. [upmcnj.com]

• Eruptions

  The time of complete resolution of pain, time of healing of skin eruption, and incidence of PHN were reported. [ncbi.nlm.nih.gov]

  Presentation The disease can be divided into the pre-eruptive phase, acute eruptive phase and chronic phase - postherpetic neuralgia (PHN). [patient.info]

• Skin Rash

  skin shingles picture, pictures of shingles blisters, shingles photos, medical shingles, free journal articles, shingles rash pictures, pictures of shingles rash, shingles skin rash pictures, pictures of shingles skin rash, shingles images, shingles [lib.uiowa.edu]

  Drug hypersensitivity syndrome is characterized by fever, skin rash and internal organ involvement. It is commonly seen with aromatic group of anticonvulsants viz. phenytoin, carbamazepine and phenobarbitone. [ncbi.nlm.nih.gov]

• Skin Patch

  Treatment options that provide pain relief include: Skin patches Anti-seizure medication Narcotic analgesics Antidepressants At UCSF Medical Center, pain management specialists also use a skin patch with capsaicin, a hot-pepper compound that's found in [ucsfhealth.org]

  You apply the patches, available only by prescription, directly to painful skin to deliver temporary relief. Capsaicin skin patch. A high concentration of an extract of chili peppers (capsaicin) is available as a skin patch to relieve pain. [upmcnj.com]

  Capsaicin skin patch A high concentration of an extract of chili peppers (capsaicin) is available as a skin patch (Qutenza) to relieve pain. [mayoclinic.org]

  Similarly, capsaicin skin patches may be used to relieve neuropathic pain, as capsaicin has known pain-blocking properties. These topical skin patches may be used for pain relief for anywhere from four to 12 hours. [paindoctor.com]

  The patch is applied to intact skin covering the most painful areas and causes a reduction in pain under and surrounding the patch. It is not generally recommended to be applied to areas of broken or seriously inflamed skin. [mhni.com]

• Suggestibility

  The review fails to find a benefit to the acyclovir at 4 or 6 months, though interestingly at one month the analysis does suggest a benefit. [thennt.com]

  These cases suggest that peripheral nerve stimulation may offer an alternative treatment option for intractable pain associated with PHN especially in the elderly where treatment options are limited because of existing comorbidities. [ncbi.nlm.nih.gov]

  Although the patients diagnosed in our clinic in their acute stages exhibited high scores for the neuropathic pain components and VAS, both declined over time suggesting early intervention by pain specialists may be useful in achieving good therapeutic [jstage.jst.go.jp]

• Irritability

  […] vs. non-irritable nociceptor). [clinicaltrialsregister.eu]

  The patch may also reduce irritation from clothing or inadvertent stimulation. Modest to moderate relief can be expected. The drug is marketed by Endo Laboratories. [mhni.com]

  The pain is a result of a change in neurological structure due to the irritation or damage of a nerve. Finding the Right Treatment for You For most patients, conservative care can relieve postherpetic neuralgia pain. [backpainok.com]

  Because of its severity and chronicity, PHN is a considerable health-care problem. 1 Fields HL Rowbotham M Baron R Postherpetic neuralgia: irritable nociceptors and deafferentation. [thelancet.com]

• Burning Sensation

  The pain is a drawing, pricking type of intense pain, sometimes accompanied with burning sensation of the skin. The pain lasts from a few weeks to few months, rarely years. [askdrshah.com]

  Some people describe the pain as an intense burning sensation. For some people, the pain can last for months or even years after the rash goes away. [cdc.gov]

  The damaged nerve sends random, uncontrolled pain signals to the brain, and causes a throbbing, burning sensation along the nerve. Over time, the confused nerves in your skin will calm. [practicalpainmanagement.com]

  sensation, sharp and stabbing, or deep and aching in nature. [emsworld.com]

  Common signs and symptoms of postherpetic neuralgia include: severe pain that continues for more than one to three months in the same place that the shingles occurred, even after the rash goes away burning sensation on the skin, even from the slightest [healthline.com]

• Insomnia

  METHODS: The Insomnia Severity Index (ISI) was used to determine the presence of clinical insomnia (ISI score ≥ 15). [ncbi.nlm.nih.gov]

  The debilitating pain can also cause fatigue, insomnia, poor appetite, and poor concentration. [brainandlife.org]

  The aim of treatment is to obtain analgesia and reduce depression and insomnia. Topical agents, systemic pharmacologic treatments, neurostimulatory techniques and neuroablative techniques have been used for this aim. [erciyesmedj.com]

  For example, he or she may experience chronic fatigue, anorexia, weight loss, reduced physical activity level, insomnia, difficulty concentrating, depression and suicidal ideations. [emsworld.com]

• Trigeminal Neuralgia

  […] with trigeminal neuralgia may generate trigeminal neuralgic pain [23]. [hindawi.com]

  ‘Touch-induced electrical pain’ sounds a lot like trigeminal neuralgia. [drhoney.org]

  A 99-year-old woman had a 4-year history of severe postherpetic (trigeminal) neuralgia on the left side of her face. [ncbi.nlm.nih.gov]

  Unlike most other neuropathic pain syndromes, such as trigeminal neuralgia or nerve root compressions, shingles has a well-defined pathogenesis and onset, as well as visible lesions, and is therefore uniquely suitable for study. [oadoi.org]

• Vertigo

  Society as a class of drugs to avoid in elderly patients. 46 Anticonvulsant medications for PHN have been associated with high incidences of dizziness and somnolence. 47,48 Opioids have numerous adverse effects including constipation, nausea, dizziness/vertigo [ajmc.com]

  Other complications include: Shingles around your eyes and forehead can cause eye infections and vision loss Shingles around or in the ear can cause hearing loss, vertigo or weakness in facial muscles Rarely, shingles spreads to the brain and spinal cord [hellolife.net]

  Symptoms and signs of vestibulocochlear dysfunction are not always present but can include hearing loss, tinnitus, vertigo, nystagmus, nausea and vomiting. [doi.org]

  When shingles affects the ear, it is called Ramsay-Hunt syndrome and can cause facial paralysis, hearing loss and vertigo. [nbcnewyork.com]

Laboratory tests

The diagnosis is usually straight forward with no need for many laboratory studies. There is usually a history of preceding herpes zoster with persistence of the pain after resolution of the rash. It may be necessary to find out the predisposing factors such as suspected human immunodeficiency virus infection, but the cause may also be obvious such as age or chemotherapy.

Imaging

Magnetic resonance imaging of the spinal level of the affect dermatome may reveal lesions, but these lesion are present even in patients whose pain does not persist [7].

• Human Herpesvirus 3

  The virus is called human herpesvirus-3, more commonly known as varicella zoster virus or VZV. It is a double-stranded DNA virus of the herpesvirales order. [symptoma.com]

  The pathogen is human herpesvirus-3 (HHV-3), also known as the varicella zoster virus (VZV). [emedicine.medscape.com]

  Synonyms: herpes zoster and varicella zoster Shingles is caused by the human herpesvirus-3 (HHV-3). Primary infection usually occurs in childhood, producing chickenpox (varicella) although it can be subclinical. [patient.info]

A number of medications have been used to treat the pain in postherpetic neuralgia including tricyclic antidepressants such as amitriptyline. Anticonvulsants, particularly gabapentin and pregabalin have also been tried and shown to be effective in controlling the pain.

Opioids have been shown to work well but the prolonged use has the risk of addiction, physical and psychological dependence. Topical agents such as capsaicin have been used with poor results currently due to its intolerability. Other tropical agents used include topical lidocaine, but data is sparse, but the little that is there shows it may be of some benefit.

Intrathecal glucocorticoids, have been used when other modalities have failed (in non-cranial neuralgia). The last options include cryotherapy of the affected nerves and surgery with variable results [8] [9] [10].

Postherpetic neuralgia is a condition that is slow to resolve, but most of the patients will respond to first line treatment with tricyclic antidepressants. A few will have refractory pain requiring more radical measures.

The virus is called human herpesvirus-3, more commonly known as varicella zoster virus or VZV. It is a double-stranded DNA virus of the herpesvirales order. After initial infection the virus remains dormant within the dorsal root ganglia until it reactivates causing herpes zoster. Most common areas of latency being the trigeminal nerve, cervical and thoracic spine [2].

The incidence rates increase with age, and with increasing impairment of immunity. The incidence in people below 20 years of age is low with a rate of 1 per 1000 and the rates in the above 80 group reaching 1 per 100. It is very common in immunocompromised patients such as patients on steroids and chemotherapy. It is also has high rates in patients suffering from human immunodeficiency virus (HIV) infection. Severe emotional stress and malnutrition are also recognised risk factors [3].

Herpes zoster (shingles) is caused by reactivation of the latent varicella zoster virus after persistence within the dorsal root ganglia. The reason for the reactivation being decreased immunity (primarily cellular immunity) due to various causes with age being the most common.

The activated virus uses the nerves transport system causing a painful neuritis, associated with a characteristic rash along the dermatome of the supplying nerve. After resolution of the rash the pain usually subsides. In those who the pain persists it is thought that there are changes to the dorsal root ganglion nerves, sensitizing them and resulting in spontaneous activity thus maintaining the continuing pain. There have been theories that persistent viral replication within the neurons causes the persistent pain [4] [5].

Early treatment of the acute herpes zoster with antivirals has shown to be beneficial. Vaccination against the varicella zoster virus to prevent initial infection has been shown to reduce the incidence of the condition.

The neuropathic pain of postherpetic neuralgia may be severe and persistent enough to significantly decrease the quality of life, with interference of normal daily activity and sleep. The pain may persist from months to years and may recur even in successfully treated patients. Postherpetic neuralgia may be very challenging to treat.

There is variability in the definitions of postherpetic neuralgia, but the most agreed upon is persistence or recurrence of pain after the acute rash of herpes zoster subsides. Others defined it as pain persisting for four months from the initial onset of the rash.

Definition: Postherpetic neuralgia is a disease that occurs after a shingles attack. Shingles is a painful rash that occurs along a nerve and usually looks like a band. The pain may be persistent and last up to years. It is common in the older population.

Cause: It is caused by the chicken pox virus (varicella zoster virus). After the initial infection with chicken pox usually in childhood, the virus goes into a dormant state and hides within the nerves usually near spinal cord. When there is a drop in immunity the virus reactivates and causes shingles which may then cause postherpetic neuralgia.

Symptoms: The predominant symptom is pain which may range from burning to stabbing in nature and this pain may persist for years and affect daily activities and sleep.

Diagnosis: The diagnosis may be made by a doctor after listening to the history and usually does not require many investigations to confirm the diagnosis. The doctor may ask for a magnetic resonance imaging (MRI) of the spine to rule out other causes.

Treatment: The treatment includes medications to control the pain. Some of the medications used are the same medications used to treat depression and epilepsy. Most patients respond to these medications, but the response may be slow and more than one type of medication may have to be used to control the pain.

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2. Burke BL, Steele RW, Beard OW, et al. Immune responses to varicella-zoster in the aged. Arch Intern Med 1982; 142:291.
3. Helgason S, Petursson G, Gudmundsson S, Sigurdsson JA. Prevalence of postherpetic neuralgia after a first episode of herpes zoster: prospective study with long term follow up. BMJ 2000; 321:794.
4. Woolf CJ. Recent advances in the pathophysiology of acute pain. Br J Anaesth 1989; 63:139.
5. LaMotte RH, Shain CN, Simone DA, Tsai EF. Neurogenic hyperalgesia: psychophysical studies of underlying mechanisms. J Neurophysiol 1991; 66:190.
6. Gilden D, Nagel MA, Mahalingam R, et al. Clinical and molecular aspects of varicella zoster virus infection. Future Neurol. Jan 1 2009;4(1):103-117
7. Haanpaa M, Dastidar P, Weinberg A, et al. CSF and MRI findings in patients with acute herpes zoster. Neurology. Nov 1998;51(5):1405-11
8. Argoff CE. Review of current guidelines on the care of postherpetic neuralgia. Postgrad Med 2011; 123:134.
9. Moore RA, Wiffen PJ, Derry S, McQuay HJ. Gabapentin for chronic neuropathic pain and fibromyalgia in adults. Cochrane Database Syst Rev 2011
10. Dubinsky RM, Kabbani H, El-Chami Z, et al. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004; 63:959.