Lasting pain after shingles
Pain that continues for a long time after a shingles rash has disappeared is called post-herpetic neuralgia. This is the most common complication of shingles. It’s still not clear how it can be prevented or what the best treatment is.
Shingles typically causes a rash accompanied by pain in the affected area. The pain normally goes away when the rash goes away. This usually happens after two to four weeks. Pain that continues for longer is referred to as post-herpetic neuralgia. The word "post-herpetic" means "post-herpes" because the pain arises after infection by the herpes zoster (shingles) virus. In very rare cases pain can come back after a shingles infection, even if it had already gone away and the rash has disappeared.
The main symptom of post-herpetic neuralgia is pain in the nerves (neuralgia). The skin is often overly sensitive and itchy as well. This can make it difficult or painful to wash yourself, turn over in bed, or hug someone. The pain and itching can be very severe and might keep you from sleeping.
What increases the risk of long-lasting pain?
The risk of developing post-herpetic neuralgia increases with age. Four weeks after getting shingles,
- 27% of 55- to 59-year-olds and
- 73% of over 70-year-olds had nerve pain.
Women seem to be more likely to have longer-lasting nerve pain than men. Post-herpetic neuralgia is also more likely to develop if your eyes were affected by shingles.
Can post-herpetic neuralgia be prevented?
People who have a severe case of shingles or who are at a higher risk of developing complications are often advised to take antiviral (virus-fighting) drugs to try to prevent post-herpetic neuralgia.
Several studies have tested whether antiviral therapy can actually prevent long-lasting nerve pain. They showed that treatment with the antiviral drug aciclovir did not prevent post-herpetic neuralgia: The same number of people still had pain both 4 and 6 months after having shingles – regardless of whether they had taken aciclovir or a fake drug (placebo).
There's not enough research on the other antiviral drugs brivudine, famciclovir and valaciclovir to be able to say whether they can prevent post-herpetic neuralgia.
In rare cases, preventive treatment with steroids is also recommended. Steroids can be taken in the form of tablets or injected into a muscle. But research has shown that this also doesn't have any advantages over treatment with a placebo.
How is post-herpetic neuralgia treated?
Lasting nerve pain can be treated in different ways:
- with anticonvulsants (anti-epileptic drugs),
- antidepressants (anti-anxiety drugs), and
- anesthetic (pain-numbing) patches.
Anticonvulsants like pregabalin or gabapentin are often used for persistent nerve pain. It takes a while for them to start working, so they are combined with painkillers to start off with. The treatment with painkillers can then be stopped.
If the anticonvulsants don't help enough, it's possible to take antidepressants as well. Both drugs reduce the transfer of pain signals to the brain and lower the sensitivity of the affected nerves.
If the pain is limited to one area of the body, patches with anesthetic drugs such as lidocaine or capsaicin could help. Studies suggest that patches with high doses of capsaicin (8%) can reduce nerve pain.
The right drug and combination will depend on how severe the pain is and how well tolerated the particular medicine is. That's why it's very important to describe the following to your doctor in as much detail as possible: how severe the pain is, how effective the drugs are and whether you experience any side effects.
There's a lack of research on other types of treatments, such as acupuncture or TENS (transcutaneous electrical nerve stimulation). So it's difficult to say for sure whether they work and how well they are tolerated.
If the pain continues despite treatment, it may be a good idea to see a specialized pain therapist or neurologist, or to contact a pain center or pain clinic.
Chen N, Li Q, Yang J, Zhou M, Zhou D, He L. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2014; (2): CD006866.
Derry S, Rice AS, Cole P, Tan T, Moore RA. Topical capsaicin (high concentration) for chronic neuropathic pain in adults. Cochrane Database Syst Rev 2017; (1): CD007393.
Derry S, Wiffen PJ, Moore RA, Quinlan J. Topical lidocaine for neuropathic pain in adults. Cochrane Database Syst Rev 2014; (7): CD010958.
Han Y, Zhang J, Chen N, He L, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2013; (3): CD005582.
Moore RA, Chi CC, Wiffen PJ, Derry S, Rice AS. Oral nonsteroidal anti-inflammatory drugs for neuropathic pain. Cochrane Database Syst Rev 2015; (10): CD010902.
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