What are the treatment options for postherpetic neuralgia (PHN)?

From the Guidelines

Postherpetic neuralgia (PHN) treatment options are primarily focused on managing pain, with first-line treatments including gabapentin, pregabalin, tricyclic antidepressants, and topical lidocaine or capsaicin patches.

Treatment Options

• Gabapentin: a commonly used first-line treatment, with a typical adult regimen titrating to 2400 mg per day in divided doses 1
• Pregabalin: considered for patients with inadequate response to gabapentin, particularly for post-herpetic neuralgia 2, 1
• Tricyclic antidepressants: effective for PHN, but may have cardiac toxicity concerns, especially in patients with ischemic cardiac disease or ventricular conduction abnormalities 3
• Topical lidocaine or capsaicin patches: useful for localized peripheral neuropathic pain, with capsaicin patches providing sustained pain relief for up to 12 weeks 4 ### Additional Considerations
• Opioids: may be considered for acute neuropathic pain or episodic exacerbations of severe pain, but with caution due to potential for dependence and side effects 3
• Non-pharmacological treatments: should be evaluated and initiated if appropriate, as part of a comprehensive pain management plan 3
• Referral to a pain specialist: may be necessary if trials of first-line medications alone and in combination fail to provide adequate pain relief 3

From the Research

Treatment Options for Postherpetic Neuralgia (PHN)

The treatment options for PHN can be classified into several categories, including:

• Pharmacologic interventions, such as tricyclic antidepressants, anticonvulsants, and opioids 5
• Topical treatments, such as lidocaine patches and capsaicin 5, 6
• Interventional treatments, such as epidural injections and pulsed radiofrequency of the dorsal root ganglion (DRG) 6
• Alternative therapies, such as electroacupuncture (EA) and osteopathic manipulative treatment (OMT) 7
• Investigational drugs, such as AT2R antagonists, VGCC α2δ subunit inhibitors, and NGF inhibitors 8

First-Line Treatments

First-line treatments for PHN include:

• Tricyclic antidepressants, such as nortriptyline 5, 6
• Gabapentin, an anticonvulsant 5, 7, 6
• Pregabalin, an anticonvulsant 7, 6
• 5% lidocaine patches, a topical treatment 7, 6

Combination Therapy

Combination therapy, using multiple treatments simultaneously, may be more effective than monotherapy for some patients 7

• Local anesthesia and gabapentin have been shown to have outstanding compatibility 7

Emerging Treatments

Emerging treatments for PHN include:

• Cryoanalgesia, a non-freezing technique using liquid nitrogen spray 9
• Investigational drugs, such as crisugabalin, mirogabalin, and fulranumab 8