A European Delphi Consensus to Support the Diagnosis, Management, and Appropriate Positioning of Topical Treatments for Postherpetic Neuralgia (PHN).

Incidence and Risk of Postherpetic Neuralgia after Varicella Zoster Virus Infection in Hematopoietic Cell Transplantation Recipients: Hokkaido Hematology Study Group

Objective: This study aims to systematically and quantitatively analyze the outcomes of radiofrequency ablation (RFA) and ultrasound-guided nerve blocks (USNB) in the treatment of postherpetic neuralgia (PHN), focusing on their efficacy, safety, and impact on pain relief and quality of life. Theoretical Framework: Postherpetic neuralgia is a common and debilitating complication of herpes zoster infection, characterized by persistent neuropathic pain that significantly affects patients' daily activities and mental well-being. Conventional pharmacological treatments often fail to provide adequate relief and are associated with undesirable side effects, necessitating the exploration of alternative interventional approaches. RFA and USNB have emerged as promising minimally invasive techniques that offer targeted pain relief with fewer systemic side effects. RFA provides prolonged pain relief by modulating nociceptive pathways, while USNB offers immediate, though temporary, pain relief by delivering anesthetic agents directly to the affected nerves. Method: A systematic review was conducted using the PubMed, Scopus, and Web of Science databases to identify relevant studies published between 2018 and 2025. The inclusion criteria focused on studies analyzing pain reduction, functional outcomes, recurrence rates, and complication profiles in PHN patients treated with RFA and USNB. Exclusion criteria eliminated studies without interventional treatments, lacking relevant outcome measures, or published in languages other than English. Results and Discussion: The review findings suggest that RFA provides more prolonged pain relief compared to USNB, with lower recurrence rates and reduced dependency on pharmacological management. However, USNB offers quicker pain relief and fewer procedural risks, making it an attractive option for immediate symptom control. Both techniques have demonstrated favorable safety profiles, though variations in patient selection and procedural execution may influence outcomes. Comparative studies indicate that a multimodal approach combining both techniques may provide optimal management for PHN. Research Implications: This study highlights the need for further large-scale, multicenter trials to establish standardized treatment protocols and assess long-term outcomes of RFA and USNB in PHN management. Future research should also focus on cost-effectiveness, patient-reported outcomes, and personalized treatment strategies to enhance clinical decision-making. Originality/Value: This systematic review provides valuable insights into the comparative effectiveness of RFA and USNB in PHN management, offering evidence to support informed clinical decision-making and improve patient outcomes. The findings contribute to the evolving landscape of interventional pain management and underscore the importance of individualized treatment strategies for PHN patients.

Postherpetic neuralgia (PHN) is a chronic, painful condition characterized by persistent pain following resolution of a herpes zoster (HZ) infection. Epidemiologic data demonstrate that the risks for HZ infections and the development of PHN increase with age. To characterize prescribing patterns, health care utilization, and treatment costs for adults with PHN based on real-world data. This study analyzed medical and pharmacy claims from 2010 to 2014 in the MarketScan Commercial and Medicare Supplemental databases. PHN patients were identified based on criteria from a published algorithm. PHN treatment patterns were analyzed by age and reported descriptively for patients aged < 65 or ≥ 65 years. Excess incremental health care costs were calculated for PHN patients by comparing expenditures for a cohort of PHN patients to expenditures of a propensity score-matched control group of patients with HZ alone. Approximately 0.4% of patients aged < 65 years were diagnosed with HZ versus 1.3% of patients aged ≥ 65 years; approximately 15.3% of HZ patients aged < 65 years and 26.4% of patients aged ≥ 65 years were diagnosed with PHN. Overall, opioids remained the most frequently prescribed initial treatment. Approximately 21.6% of PHN patients received an opioid as an initial treatment for PHN, 15.1% received gabapentin; 8.9% received a prescription nonsteroidal anti-inflammatory drug (NSAID); 8.3% received a lidocaine patch; 3.3% received pregabalin; 2.5% received a tricyclic antidepressants (TCAs); 0.8% received other topical lidocaine; and < 1% received capsaicin. Observed first-line use of the lidocaine patch and gabapentin was higher in patients aged ≥ 65 years relative to patients aged < 65 years. When separated by age group, only 24.6% of patients aged < 65 years and 38.5% of patients aged ≥ 65 years were prescribed a recommended first-line treatment for initial PHN therapy (gabapentin, lidocaine patch, pregabalin, and TCAs). Comparisons of treatment costs of PHN patients to matched HZ patients without PHN indicated that PHN patients initiated on opioids had the highest mean additional health care expenditure compared with PHN patients initiated on other medications. On average, PHN patients initiated on opioids had $7,601 additional health care expenditure compared with HZ patients with no PHN; additional expenditures were $6,428 for pregabalin, $4,213 for lidocaine patches, $3,478 for gabapentin, $3,304 for NSAIDs, and $2,797 for TCAs, respectively. Management of PHN is associated with substantial utilization of opioid-based therapies across all ages. Medications supported by evidence either as first-line therapies or as part of a multimodal regimen for the management of PHN are underused relative to opioid-based PHN therapies. Improving adherence to evidence-based PHN treatment regimens offers the potential to reduce opioid prescribing first line and reduce overall treatment costs. Given the emphasis to reduce opioid prescribing to minimize the risk of dependence, abuse, and diversion, multimodal analgesic treatments that can avoid or reduce opioid use should be considered. Research funding was provided by SCILEX Pharmaceuticals. The sponsor reviewed and approved the research plan and provided support for manuscript preparation through Patel's role as a coauthor of this manuscript. The sponsor's product (lidocaine patch) was not used in this study. Patel is a paid employee of SCILEX Pharmaceuticals. Goss is an employee and minority owner of Boston Healthcare Associates, which received a research grant from SCILEX Pharmaceuticals to conduct this study. Gudin reports advisory board fees from AcelRx Pharmaceuticals and BioDelivery Sciences International and consulting fees from Averitas, Daiichi, Hisumitsu, Nektar, Purdue, Quest Diagnostics, SCILEX Pharmaceuticals, and US WorldMeds, unrelated to this study. Fudin reports advisory board fees from AcelRx Pharmaceuticals, Human Half-Cell, Quest Diagnostics, GlaxoSmithKline, SCILEX Pharmaceuticals, BioDelivery Sciences, Daiichi Sankyo, and Salix Pharmaceuticals; speaker fees from Daiichi Sankyo, Salix Pharmaceuticals, Abbott Laboratories, Acutis Diagnostics, and AstraZeneca; and consulting fees from Firstox Laboratories, unrelated to this study. The other authors have nothing to disclose. Parts of this research were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting; April 22, 2016; San Francisco, CA, and at the 35th Annual Scientific Meeting of the American Pain Society; May 11-14, 2016; Austin, TX.

UK experience of herpes zoster vaccination can inform varicella zoster virus policies

Patient characteristics and analgesic efficacy of antiviral therapy in postherpetic neuralgia

Post Herpetic Neuralgia (PHN) is a chronic potentially debilitating resistant neuropathic pain. This is a single in-depth case study conducted to assess the effectiveness of Yoga Prana Vidya (YPV) Healing in the Management of PHN. Experience has shown that YPV is an effective noninvasive non-drug therapy for several ailments and this study has used YPV in the management of this severe painful condition. A 45 year old male patient suffering from PHN was treated with a set of YPV protocols. The patient was treated earlier with conventional therapy consisting of Opioid Analgesic Pentazocin injection, sedatives like valium, tricyclic antidepressant like Gapapentin for four months duration with little relief from pain. The patient was advised to perform self-practice of some YPV protocols including rhythmic yogic breathing 2-3 times a day. Initially healing was done three times a day for 3 days and then once a day for 4 days. During the first healing session, the patient slept in clinic and got relief in the pain by 20%. On the same day in the night he slept for 7 hours. Within a week the patient was completely relieved of his pain, stopped taking any analgesic, psychotropic drugs, and resumed his daily chores. YPV worked well in this case as an effective alternative noninvasive nondrug, non -touch therapy for the relief of pain in PHN when the conventional therapy was not effective and offers scope for targeted research in this field.

Evaluation of Varicella Zoster Prophylaxis after Allogeneic Hematopoietic Cell Transplantation Using Valacyclovir Followed By Vaccination

Background: Herpes zoster affects millions of people worldwide each year and many go on to suffer long-term pain, called postherpetic neuralgia (PHN). As zoster is common and PHN is difficult to treat, preventing zoster through vaccination is important. This thesis aims to better understand risk factors for zoster and PHN, in order to inform vaccination policy. Methods: Three large observational studies were carried out using primary care data from the UK Clinical Practice Research Datalink and linked secondary care data from the Hospital Episodes Statistics. First, a matched case-control study quantified the effects of possible risk factors for zoster and explored whether their effects differed by age group. Second, a descriptive study looked at antiviral prescription patterns and patient characteristics associated with antiviral receipt after zoster diagnosis. Third, a cohort study assessed risk factors for PHN and investigated whether their effects were modified by antiviral use. Results: The case-control study of zoster risk factors included 144,959 zoster patients and 549,336 controls and found an increased risk of zoster among patients with rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, chronic obstructive pulmonary disease, asthma, chronic kidney disease, depression and type 1 diabetes; odds ratios ranged from 1.14 to 1.72. In general, the relative effects of these risk factors on zoster decreased with increasing age. In the descriptive study of antiviral use, of 142,216 zoster cases, only 58.1% received an antiviral prescription at zoster diagnosis. Antivirals were even under-prescribed among the immunosuppressed and older individuals, for whom guidelines recommend routine treatment. The cohort study of PHN risk factors identified 119,413 zoster patients, 5.8% of whom developed PHN. An increased risk of PHN was found among patients with rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, chronic obstructive pulmonary disease, asthma, depression, type 2 diabetes, lower socioeconomic status, smoking and under- or overweight; odds ratios ranged from 1.13-1.82. Antiviral use was not associated with PHN risk overall. The zoster case-control and PHN cohort study showed that patients with severely immunosuppressive conditions were at greatest risk of both zoster and PHN. Conclusions: A number of patient characteristics and comorbidities were associated with increased zoster and PHN risks. Patients at highest risk of zoster and PHN are those of older age and those with immunosuppression; currently, patients with immunosuppression are not eligible for vaccination, highlighting a need for alternative risk reduction strategies in this group. Low antiviral use at zoster diagnosis suggests treatment guidelines be revised to encourage greater use, especially among the immunosuppressed and older individuals who are recommended, but not routinely given, antivirals. Research on the cost-effectiveness of vaccinating patients with specific risk factors is needed.

Anesthesia Literature Review

Herpes zoster (HZ), caused by reactivation of the varicella-zoster virus, primarily affects older or immunocompromised individuals and can lead to painful skin rashes and long-term complications such as postherpetic neuralgia (PHN). In Europe, approximately 1.7 million people are affected annually, with a lifetime risk of 20-30% that increases with age. PHN develops in 10-20% of cases and in up to 50% of individuals over 85. The disease progresses through three stages: a prodromal phase with localized pain, an acute phase with a vesicular rash, and a chronic phase often marked by persistent neuropathic pain. PHN is defined as pain lasting three months or more after the rash has resolved. Diagnosis is usually clinical, with PCR testing used in atypical presentations. Vaccination with the recombinant adjuvanted vaccine (Shingrix) is recommended for adults aged 60 and older and has proven effective in preventing both HZ and PHN. Antiviral therapy, such as aciclovir, should be initiated within 72 hours of symptom onset. Pain management depends on the severity and type of pain and may involve NSAIDs, opioids, anticonvulsants like pregabalin, antidepressants, as well as topical or interventional approaches in difficult cases. HZ represents a significant health burden, particularly in older adults, and prevention through vaccination along with early treatment is essential to reduce complications and improve patient outcomes.

Herpes zoster (HZ) and postherpetic neuralgia (PHN) are common diseases in a pain clinic. In Korea, the rate of clinical visits due to the incidence of herpes zoster was 7.93-12.54/1000 annually [1]. PHN is a painful neuropathy and the most common complication of HZ. A complete recovery from PHN is difficult for doctors despite of proper HZ treatment. In spite of the treatment, some patients suffered from severe PHN for several years. Therefore, the most important aspects are the risk factor of PHN and the method of prevention of PHN. In this issue of the Korean Journal of Pain (KJP), Jung et al. [2] reported the incidence of HZ in Cheonan, Korea. The results show that patients 50 years and older have a higher incidence of HZ, and the most common site of HZ was the thoracic nerve (47.9%), followed by the trigeminal nerve (21.4%). The incidence rate was similar to the affected site of PHN (thoracic area: 52.9%, trigeminal area: 15.6%) in Korea [3]. In patients who suffer from HZ, the risk factors of PHN are old age, presence of a painful prodrome, severe pain of HZ, severe rash, and immuno-compromised status [4,5,6]. In patients with HZ over 60 years, up to 25% progressed to PHN [7]. The proportion of PHN increases steadily from young ages up to 80-84 years [8]. Therefore, patients who are elderly and possess the risk factor with HZ must undergo more intensive treatment. The main treatment of HZ is medication and interventional therapy. Taking antiviral medication beginning within 72 hrs of rash onset is usually recommended [7,9,10]. Two meta-analyses suggest that the antiviral medication can reduce the overall duration of pain and incidence of PHN [11,12]. Epidural injection with a steroid within 2 months of HZ development is also recommended for the prevention of PHN [13]. In the previous survey of Korea, epidural injection was the most commonly performed interventional treatment in PHN patients [3]. Other interventions such as paravertebral block, peripheral block and sympathetic block are clinically effective for the treatment of HZ and PHN. For evidence-based medicine of interventional treatment of HZ and PHN, the investigations of randomized controlled trials regarding the interventions will be necessary. In this issue, Jeon et al. [10] described the prevention and treatment of HZ and PHN. They mention that vaccination against varicella zoster virus (VZV) can be the first line for the prevention of HZ and PHN. A previous review article reported that vaccination of VZV reduced morbidity from HZ and PHN [14]. Vaccination of VZV reduced the occurrence of herpes zoster by approximately 70% in individuals aged 50-59 years old [15]. In persons 60 years or older, the vaccination reduced the burden of illness from HZ by 61.1% and the risk of PHN by 66.5% [16]. Therefore, the vaccination of patients over 50 years old can be effective for the prevention of HZ and PHN. Although PHN is difficult to treat, early and intensive treatment of patients with HZ can reduce the occurrence of PHN. In healthy elderly people, a vaccination of VZV can also decrease the incidence of HZ and PHN.

Post-herpetic neuralgia is an unpleasant complication of shingles, that predominantly affects older people. Margaret Perry discusses the prevalence, risk factors and managment of this challenging condition Shingles, or herpes zoster, will affect 10–20% of the population at some point in their life. Post-herpetic neuralgia is a complication of shingles that is more common in older people. Post-herpetic neuralgia results in persisting pain which may continue for months or even years after the shingles rash has resolved. The pathophysiology of this condition is not well understood. Risk factors for developing post-herpetic neuralgia include the site of the shingles rash and age. The management of post-herpetic neuralgia can be difficult and the risk of interaction with other medications must be considered, particularly in older people. Vaccination can reduce the risk of shingles and the incidence of complications.

General practice p 794 Shingles, or herpes zoster, may occur at any stage in a person's life. Herpes zoster is the clinical manifestation of the reactivation of a lifelong latent...

Herpes zoster (HZ) is a disease triggered by the reactivation of latent varicella zoster virus (VZV) in spinal or cranial sensory ganglia, and is characterized by a painful vesicular eruption in the affected dermatome. Postherpetic neuralgia (PHN) is a chronic, neuropathic pain that can persist long beyond resolution of visible cutaneous manifes‐ tations which is often resistant to current analgesic treatments. The lifetime prevalence of herpes zoster is approximately 20–30% and about 9–34% of these patients develop PHN depending on its definition. Clinical experience has shown that PHN often develops in cases of inadequate initial pain management resulting in increased pain intensity. This review provides an overview of the treatment options for HZ and PHN, focusing on the therapeutic modalities of pain management. The primary objectives of management of HZ are to inhibit viral replication, relieve pain, and prevent associated complications, such as PHN. General treatments for acute HZ are combination of antiviral therapy with a short course of corticosteroids at the onset of the disease in conjunction with an effective control of acute pain, including nonsteroidal anti-inflammatory drugs, acetaminophen, opioids, and anticonvulsants such as gabapentin or pregabalin. Treatment of PHN is often resistant to the current pharmacologic methods. Therefore, a multimodal analgesic treatment regimen including topical lidocaine and capsaicin, systemic therapies, and the interventional treatments is necessary to alleviate pain and its effect on quality of life. As the incidence of HZ increases with age, the number of patients with HZ and PHN may increase in the future considering the gradual aging of the general population. Appro‐ priate management of HZ can reduce the duration and intensity of pain from HZ, and prevent the development of PHN. In addition, prophylactic zoster vaccination can prevent or reduce the incidence of HZ and PHN. Further efforts are needed to minimize pain of the patients suffering from HZ and PHN as it affects the quality of life in the aspect of both physical and psychological impairments.

Herpes Zoster Eye Disease: New Ways to Combat an Old Foe?