Chronic Pain and Postherpetic Neuralgia

  • Beth VanderWielen
  • Alaa Abd-Elsayed


Herpes zoster is a well-known ubiquitous, painful rash which presents in a dermatomal distribution often among aging and/or immunosuppressed populations. One of the most common but devastating sequela of varicella zoster infection, or shingles, is chronic pain at the infected site known as postherpetic neuralgia. Early diagnosis is critical to initiate timely antiviral and neuropathic pain medications to support the individuals’ ability to maintain functional status and quality of life. Fortunately, since 2017, a new FDA-approved vaccine is available in an effort to improve efficacy and sustainability of immunological response. This chapter reviews the diagnosis, pathophysiology, medical and interventional treatments, immunization recommendations, and future directions for further investigation of varicella zoster virus and treatment of postherpetic neuralgia.


Postherpetic neuralgia Herpes zoster Shingles Varicella zoster virus Chicken pox 


  1. 1.
    Albrecht M. Clinical features of varicella-zoster virus infection: chickenpox. In: UpToDate, Post TW (editors). UpToDate. Waltham. Accessed on 09 May 2018.Google Scholar
  2. 2.
    Koshy E, Mengting L, Kumar H, Jianbo W. Epidemiology, treatment and prevention of herpes zoster: a comprehensive review. Indian J Dermatol Venereol Leprol. 2018;84:251–62.PubMedGoogle Scholar
  3. 3. Shingles (Herpes Zoster): for health care professionals. CDC. [Internet] 2018. [Accessed 25 May 2018.] Available from:
  4. 4.
    Van Wijck A, Opstelten W, Moons K, Van Essen G, Stolker R, Kalkman C, Verheij T. The PINE study of epidural steroids and local anaesthetics to prevent postherpetic neuralgia: a randomized controlled trial. Lancet. 2006;367(9506):219–24.CrossRefGoogle Scholar
  5. 5.
    Shailesh G, Parikh V, Parikh R. Herpes zoster oticus: a rare clinical entity. Contemp Clin Dent. 2010;12(2):127–9.Google Scholar
  6. 6.
    Saguil A, Kane S, Mercado M. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2017;96(10):656–63.PubMedGoogle Scholar
  7. 7.
    Harpaz R, Ortega-Sanchez I, Seward J. CDC: prevention of herpes zoster: recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep. 2008;57(05):1–30.PubMedGoogle Scholar
  8. 8.
    Lexicomp® Online. Acyclovir (systemic): drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  9. 9.
    Lexicomp® Online. Famciclovir: drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  10. 10.
    Lexicomp® Online. Valacyclovir (systemic): drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  11. 11.
    Han Y, Zhang J, Chen N, He L, Zhou M, Zhu C. Corticosteroids for prevention postherpetic neuralgia. Cochrane Database Syst Rev. 2013;3:1–31.Google Scholar
  12. 12.
    Lexicomp® Online. Gabapentin: drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  13. 13.
    Rauck R, Irving G, Wallace M, Vanhove G, Sweeney M. Once-daily gastroretentive gabapentin for postherpetic neuralgia: integrated efficacy, time to onset of pain relief and safety analyses of data from two phase 3, multicenter, randomized, double-blind placebo-controlled studies. J Pain Symptom Manag. 2013;46(2):219–28.CrossRefGoogle Scholar
  14. 14.
    Fan H, Yu W, Zhang Q, Cao H, Li J, Wang J, Shao Y, Hu X. Efficacy and safety of gabapentin 1800mg treatment for post-herpetic neuralgia: a meta-analysis of randomized controlled trials. J Clin Pharm Ther. 2014;39(4):334–42.CrossRefGoogle Scholar
  15. 15.
    Lexicomp® Online. Pregabalin: drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  16. 16.
    Lexicomp® Online. Amitriptyline: drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  17. 17.
    Lexicomp® Online. Nortriptyline: drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  18. 18.
    Lexicomp® Online. Desipramine: drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  19. 19.
    Lexicomp® Online. Capsiacin: drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  20. 20.
    Lexicomp® Online. Lidocaine (topical): drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  21. 21.
    Xu G, Zhong-Wei L, Feng Y, Tang W, Xu G. A single-center randomized controlled trial of local methylcobalamin injection for subacute herpetic neuralgia. Pain Med. 2013;14:884–94.CrossRefGoogle Scholar
  22. 22.
    Schencking M, Vollbracht C, Weiss G, Lebert J, Biller A, Goyvaerts B, Kraft K. Intravenous vitamin C in the treatment of shingles: results of a multicenter prospective cohort study. Med Sci Monit. 2012;18(4):215–24.CrossRefGoogle Scholar
  23. 23.
    Lexicomp® Online. Zinc sulfate: drug information. Hudson: Lexi-Comp, Inc; 2018.Google Scholar
  24. 24.
    Lin Y, Lan K, Want L, Chen J. Treatment of postherpetic neuralgia with intravenous administration of zinc sulfate: a case report. A A Pract. 2018;11(1):8–10.CrossRefGoogle Scholar
  25. 25.
    Dureja G, Usmani H, Khan M, Tahseen M, Jamal A. Efficacy of intrathecal midazolam with or without epidural methylprednisolone for management of post-herpetic neuralgia involving lumbosacral dermatomes. Pain Physician. 2010;13(3):213–21.PubMedGoogle Scholar
  26. 26.
    Pasqualucci A, Pasqualucci V, Galla F, De Angelis V, Marzocchi V, Coulssi R, et al. Prevention of post-herpetic neuralgia: acyclovir and prednisolone versus epidural local anesthetic and methylprednisolone. Acta Anaesthesiol Scand. 2000;44:910–8.CrossRefGoogle Scholar
  27. 27.
    Kim H, Ahn H, Lee J, Choi S, Cheong Y, Kwon K, Yoon S, Leem J. Effects of applying nerve blocks to prevent postherpetic neuralgia in patients with acute herpes zoster: a systemic review and meta-analysis. Korean J Pain. 2017;30(1):3–17.CrossRefGoogle Scholar
  28. 28.
    Calandria L. Cryoanalgesia for post-herpetic neuralgia: a new treatment. Int J Dermatol. 2011;50(6):746–50.CrossRefGoogle Scholar
  29. 29.
    Eldabe S, Buschser E, Duarte R. Complications of spinal cord stimulation and peripheral nerve stimulation techniques: a review of the literature. Pain Med. 2016;17(2):325–36.PubMedGoogle Scholar
  30. 30.
    Harke H, Gretenkort P, Ladleif H, Koester P, Rahman S. Spinal cord stimulation in postherpetic neuralgia and in acute herpes zoster pain. Anesth Analg. 2002;94(3):694–700.CrossRefGoogle Scholar
  31. 31.
    Merck. [Internet]. 2018 [cited 11 May 2018]. Available from:
  32. 32.
    Drug and device news. P T. 2017;42(12):726–63.Google Scholar
  33. 33.
    Kawai K, Gebremeskel B, Acosta C. Systematic reviews of incidence and complications of herpes zoster: towards a global perspective. BMH Open. 2014;4(6):E 004833.CrossRefGoogle Scholar
  34. 34.
    Chen L, Arai H, Chen L, Chou M, Djauzi S, Dong B, et al. Looking back to move forward: a twenty-year audit of herpes zoster in Asia- Pacific. BMC Infect Dis. 2017;17(213):2–39.Google Scholar
  35. 35.
    Oranje A, Folkers E. The Tzanck Smear: old, but still of inestimable value. Pediatr Dermatol. 1988;5(2):127–9.CrossRefGoogle Scholar
  36. 36.
    Kurklinsky S, Palmer SC, Arroliga MJ, Ghazi SM. Neuromodulation in postherpetic neuralgia: case reports and review of the literature. Pain Med. 2018;19(6):1237–44.CrossRefGoogle Scholar
  37. 37.
    National Institute of health: US. National Library of Medicine. [Internet] 2018. [Accessed 01 May 2018]. Available from:

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Beth VanderWielen
    • 1
  • Alaa Abd-Elsayed
    • 2
  1. 1.Department of AnesthesiologyUniversity of Wisconsin-Madison Hospitals and ClinicsMadisonUSA
  2. 2.Department of AnesthesiologyUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA

Personalised recommendations