From the Research
For shingles pain on the face in a 77-year-old male already taking Valtrex, I recommend starting with acetaminophen (Tylenol) 650-1000 mg every 6 hours as needed, not exceeding 3000 mg daily due to age-related liver concerns. If this provides insufficient relief, consider adding an NSAID like ibuprofen 400-600 mg every 6 hours with food if there are no contraindications such as kidney disease, heart failure, or bleeding risk. For more severe pain, gabapentin starting at 100-300 mg at bedtime and gradually increasing to three times daily can help with nerve pain, as seen in a study where combination treatment with gabapentin and valacyclovir reduced the incidence of postherpetic neuralgia 1. Lidocaine 5% patches applied to the affected area for 12 hours daily (if not near eyes) may provide topical relief. Avoid opioids if possible due to side effect risks in older adults. The pain management approach should complement the antiviral therapy (Valtrex), which reduces viral replication but doesn't directly address pain. Prompt pain control is important as it may reduce the risk of developing postherpetic neuralgia, a persistent pain condition that can follow shingles, which is more common in older adults. A recent study comparing valacyclovir and famciclovir found valacyclovir to be more efficacious in managing herpes zoster, with significant benefits in pain resolution 2. However, the most recent and highest quality study relevant to pain management in this context is from 2018, which found that combination therapy with valacyclovir, methylprednisolone, and pregabalin has better efficacy compared to valacyclovir and pregabalin and valacyclovir alone in the management of acute herpes zoster neuralgia 3. Therefore, considering the patient is already on Valtrex, adding pregabalin and possibly a short course of methylprednisolone under close supervision could be beneficial for severe cases, based on the study by 3.