From the Guidelines
Postherpetic neuralgia (PHN) treatment should prioritize a multimodal approach, focusing on pain relief with first-line treatments including topical agents such as lidocaine 5% patches or capsaicin 8% patches, and oral medications like gabapentin or pregabalin, as these have shown efficacy in reducing pain and improving quality of life 1.
Treatment Options
The treatment of PHN involves a combination of pharmacological and non-pharmacological approaches.
- Topical agents:
- Lidocaine 5% patches applied to the painful area for 12 hours daily
- Capsaicin 8% patches applied by healthcare providers for 30-60 minutes every 3 months
- Oral medications:
- Anticonvulsants like gabapentin (starting at 300mg daily and titrating up to 1800-3600mg daily in divided doses) or pregabalin (starting at 75mg twice daily and increasing to 150-300mg twice daily)
- Tricyclic antidepressants such as amitriptyline (10-25mg at bedtime, increasing to 75-150mg if needed)
Considerations for Treatment
For severe cases, opioids like tramadol or oxycodone may be considered short-term, but their long-term use is discouraged due to addiction potential 1. Combination therapy often works better than monotherapy, and non-pharmacological approaches including physical therapy, transcutaneous electrical nerve stimulation (TENS), and psychological interventions like cognitive behavioral therapy can complement medication 1.
Individualized Treatment
Treatment should be individualized based on pain severity, comorbidities, and medication tolerability, with regular reassessment to optimize pain control while minimizing side effects 1. Gabapentin is recommended as a first-line oral pharmacological treatment of chronic HIV-associated neuropathic pain, with a typical adult regimen titrating to 2400 mg per day in divided doses 1. If patients have an inadequate response to gabapentin, clinicians might consider a trial of pregabalin for patients with post-herpetic neuralgia 1.
From the FDA Drug Label
The efficacy of pregabalin for the management of postherpetic neuralgia was established in three double-blind, placebo-controlled, multicenter studies The efficacy of gabapentin as adjunctive therapy was not relevant to this question, however, gabapentin was evaluated for the management of postherpetic neuralgia (PHN) in two randomized, double-blind, placebo-controlled, multicenter studies. In adults with postherpetic neuralgia, gabapentin may be initiated on Day 1 as a single 300 mg dose, on Day 2 as 600 mg/day (300 mg two times a day), and on Day 3 as 900 mg/day (300 mg three times a day).
The treatment options for postherpetic neuralgia (PHN) include:
- Pregabalin: The dosage is not specified in the provided text, but it was shown to be effective in three double-blind, placebo-controlled, multicenter studies 2.
- Gabapentin: The recommended dosage is 300 mg on Day 1,600 mg/day on Day 2, and 900 mg/day on Day 3, with a maximum dose of 1800 mg/day 3 3. Note that the dosage may need to be adjusted based on renal function 3.
From the Research
Treatment Options for Postherpetic Neuralgia (PHN)
The treatment options for PHN include:
- Pharmacological treatments such as tricyclic antidepressants, gabapentin, pregabalin, and 5% lidocaine patches as first-line medications 4
- Gabapentin, which has been investigated extensively, especially the gabapentin enacarbil (GEn) formulation 4
- Combinational therapy, which is more effective than monotherapy, with local anesthesia and gabapentin showing outstanding compatibility 4
- Interventional treatments, including transcutaneous electrical nerve stimulation, local botulinum toxin A, cobalamin, and triamcinolone injection, intrathecal methylprednisolone and midazolam injection, stellate ganglion block, dorsal root ganglion destruction, and pulsed radiofrequency therapy 5
- Alternative therapies such as electroacupuncture (EA) and osteopathic manipulative treatment (OMT), which have shown efficacy in alleviating pain in some cases 4
Pharmacological Treatments
Pharmacological treatments for PHN include:
- Gabapentin, which has been shown to be effective in reducing PHN pain and improving sleep and quality of life 6, 7, 8
- Pregabalin, which is also used as a first-line medication for PHN 4
- Tricyclic antidepressants, which are commonly used to treat PHN 4, 5
- 5% lidocaine patches, which are used as a first-line medication for PHN 4
Interventional Treatments
Interventional treatments for PHN include:
- Transcutaneous electrical nerve stimulation, which is recommended as a first-line interventional treatment 5
- Local botulinum toxin A and triamcinolone injection, which are recommended as first-line interventional treatments 5
- Stellate ganglion block, which is recommended as a first-line interventional treatment 5
- Spinal cord stimulation, which is considered for patients with severe pain that persists despite other treatments 5