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].

• Varicella-Zoster Virus Infection

  Postherpetic neuralgia (PHN) is the most common complication following an acute varicella zoster virus infection. PHN often results in a chronic severe pain condition refractory to conservative pain management treatments. [ncbi.nlm.nih.gov]

  T.Minsue Chen, Saira George, Christy A Woodruff and Sylvia Hsu, Clinical manifestations of varicella-zoster virus infection, Dermatologic Clinics, 20, 2, (267), (2002). [doi.org]

• Fever

  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]

  No participant had grade 3 fever in either of the groups. [doi.org]

  Other symptoms of shingles can include Fever Headache Chills Upset stomach [web.archive.org]

  Known clinically as varicella-zoster, the infection is characterized by mild fever and an itchy, red, inflamed rash that often leaves scars from incessant scratching. Once chickenpox passes, people are usually immune to it. [aaa1b.org]

• Localized Pain

  […] symptom, local pain, local redness and local swelling or consent withdrawal. [doi.org]

  The vesicular mucocutaneous eruptions of HZ are usually preceded by two or three days of localized pain, and the acute neuritis that accompanies the eruptions may sometimes leave the legacy of postherpetic neuralgia (PHN). [hindawi.com]

• Chills

  Other symptoms of shingles can include Fever Headache Chills Upset stomach [web.archive.org]

  But if it’s something you’re not used to, your body can still feel the chill, which can be aggravated further if you have circulation problems. Your toes or fingers can tingle or even turn a blue hue. [mainespinenerve.com]

  Other symptoms may include: Headache Fever Chills Upset stomach Because these latter symptoms are present in many illnesses, including the common flu virus, it’s essential to seek treatment early to ensure the fastest recovery from PHN. [aaa1b.org]

  The most common side effects with Shingrix (which may affect more than 1 in 10 people) are reactions at the site of injection (such as pain, redness and swelling), chills, fever, muscle pain, tiredness, headache and side effects of the digestive system [ema.europa.eu]

• Surgical Procedure

  Microvascular decompression for classical trigeminal neuralgia is a major surgical procedure in which the compressing blood vessels are separated from the trigeminal nerve root in the posterior fossa. [hindawi.com]

  They can include referring the patient to a physiotherapist, prescribing medications, or recommending a surgical procedure. Some neurologists specialize in certain parts of the nervous system or in specific procedures. [en.wikipedia.org]

  Recorded information includes the civil registration number, the dates of admission and discharge, the surgical procedures performed, and up to 20 discharge diagnoses. [doi.org]

  CXL is a minimally-invasive surgical procedure that combines a photosensitive solution applied to the cornea with a low dose of UV light. [nei.nih.gov]

• 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]

• Ulcer

  KEYWORDS: herpes zoster; peptic ulcer; postherpetic neuralgia; risk factors [ncbi.nlm.nih.gov]

  There is risk of neuropathic ulceration and exposure keratopathy. There is also a risk of complications common to the disease elsewhere, such as PHN. [patient.info]

  If you have heart disease, high blood pressure, kidney disease, or have had stomach ulcers or bleeding, talk with your health care provider before using these medicines. You may also take acetaminophen (such as Tylenol) for pain relief. [medlineplus.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]

• Pruritus

  Figures and Tables - Analysis 2.10 Comparison 2 Zoster vaccine versus placebo subgroup analysis by age, Outcome 10 Pruritus inoculation site. [dx.doi.org]

  Chronic pruritus can be present. More than 90% of patients who have PHN have allodynia, 7 which tends to occur in areas where sensation is relatively preserved. Patients also feel spontaneous pain in areas where sensation is lost or impaired. [jfponline.com]

  Lotions containing calamine (e.g., Caladryl) may be used on open lesions to reduce pain and pruritus. Once the lesions have crusted over, capsaicin cream (Zostrix) may be applied. [web.archive.org]

  […] 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, somnolence, vomiting, pruritus [ajmc.com]

  Secondary outcomes Adverse events: local or systemic reactions (for example, pain, pruritus, swelling, headache) occurring at any time after vaccination. Drop‐outs. [doi.org]

• Sweating

  Motor dysfunction (this is rare): Autonomic dysfunction (eg sweating) Organ damage (eg blindness if there is ophthalmic involvement) Chronic pain can lead to insomnia, anxiety and depression. [dermnetnz.org]

  Common side effects of tramadol can include: nausea (feeling sick) dizziness constipation sweating dry mouth confusion headache vomiting Like all opioids, tramadol can be addictive if taken over long periods of time, so it should be prescribed for the [your.md]

  Pilocarpine (5 mg po tid) may be given after ophthalmologic and cardiorespiratory contraindications are excluded; adverse effects include sweating, flushing, and polyuria. [merck.com]

• Headache

  We also have a dedicated headache clinic for those children suffering from headaches. What is Postherpetic Neuralgia (Shingles)? Postherpetic neuralgia is a complication of the painful shingles rash, which is caused by the chickenpox virus. [childrens.com]

  The most commonly reported adverse events were nausea, vomiting, diarrhoea and headache for aciclovir, and headache and nausea for famciclovir. For neither treatment was the incidence of adverse events significantly different from placebo. [ncbi.nlm.nih.gov]

  The International Classification of Headache Disorders 3rd edition On behalf of the Classification Committee of The International Headache Society I am proud to present the third edition of the International Classification of Headache Disorders (ICHD- [ihs-classification.org]

  These include the following: trigeminal neuralgia post-herpetic neuralgia de-afferentation neuropathic pain cluster headache migraine A more extensive list of the causes of facial pain includes the following: dental problems (e.g. cavities, tooth abcess [drhoney.org]

• 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]

• Hyperesthesia

  Hyperesthesias, allodynia, and burning pain persisted despite nonsteroidal antiinflammatory agents, codeine and hydrocodone. Oral opioids were administered until sedation occurred, with no relief of pain. [ncbi.nlm.nih.gov]

  Hyperalgesia, hyperesthesia or allodynia may also be associated20. Excruciating pain in bite or sting has been more often reported for acute HZ and burning pain is more common in PHN patients11. [scielo.br]

  […] pathologic studies have demonstrated damage to the sensory nerves, the sensory dorsal root ganglia and the dorsal horns of the spinal cord in patients with this condition. 9 Clinical Presentation Herpes zoster typically presents with a prodrome consisting of hyperesthesia [web.archive.org]

• Peripheral Neuropathy

  OBJECTIVES: The pregabalin dose-response for pain, Patient Global Impression of Change (PGIC), and sleep quality measures in painful diabetic peripheral neuropathy (pDPN), postherpetic neuralgia (PHN), and fibromyalgia (FM) is relevant for physicians [ncbi.nlm.nih.gov]

  Management / Guidelines: The following links provide up to date, evidence based guidance and guidelines on managing pain due to peripheral neuropathy. Many of the links deal with management of neuropathic pain in general. [paincommunitycentre.org]

  The NUCYNTA franchise includes: NUCYNTA ER (tapentadol) extended release tablets indicated for the management of pain, including neuropathic pain associated with diabetic peripheral neuropathy (DPN), severe enough to require daily, around-the-clock, long-term [news-medical.net]

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.
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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.