From the Guidelines
For pain associated with shingles (postherpetic neuralgia) when gabapentin isn't effective and lidocaine patches provide only partial relief, consider trying pregabalin (Lyrica) at 75-150mg twice daily, which works similarly to gabapentin but may be more effective for some patients. This recommendation is based on the evidence from the 2017 HIVMA of IDSA clinical practice guideline for the management of chronic pain in patients living with HIV, which found that pregabalin had an analgesic efficacy with a number needed to treat (NNT) of 4.93 1.
Treatment Options
Other treatment options that may be considered include:
- Tricyclic antidepressants like amitriptyline (10-25mg at bedtime) or nortriptyline (10-25mg at bedtime), which have been found to be effective in treating postherpetic neuralgia 1
- Capsaicin 8% patches applied for 30-60 minutes every three months by a healthcare provider, which may provide significant relief 1
- Topical lidocaine patches, which have been found to be effective in reducing pain in patients with postherpetic neuralgia 1
- Opioids like tramadol, which may be considered short-term for severe cases 1
Mechanism of Action
These medications work by either blocking pain signals (lidocaine, capsaicin), modulating nerve transmission (pregabalin, tricyclics), or affecting pain perception (opioids) 1.
Combination Therapy
Combining treatments often works better than single therapies, and nerve blocks performed by pain specialists can help in resistant cases 1. Most patients experience improvement over time, though complete resolution may take months to years. It's essential to consider each patient's presentation and comorbidities and often follow a trial-and-error approach to achieve pain reduction and improve quality of life 1.
From the Research
Treatment Options for Pain Associated with Shingles
- Gabapentin, an alpha-2 delta ligand, is often used to treat post-herpetic neuralgia (PHN), but its effectiveness can vary among patients 2, 3.
- Topical analgesics, such as 5% lidocaine patch, can provide relief for some patients, especially when used in combination with systemic agents 2, 4.
- Other treatment options for PHN include tricyclic antidepressants, anticonvulsants, and opioids, which can have significant side effect profiles 2, 3, 4.
Efficacy of Lidocaine Patches
- Lidocaine patches have been shown to be effective in relieving pain associated with acute herpes zoster and PHN 5.
- A study found that lidocaine patch 5% applied twice a day can provide significant pain relief during rest and movement, with a low incidence of adverse events 5.