What are the best topical treatments for pain relief in shingles?

Topical Pain Relief Options for Shingles

Lidocaine patches (5%) are the most effective first-line topical treatment for shingles pain, providing immediate relief with minimal systemic absorption. 1

First-Line Topical Treatments

1. Lidocaine patches/cream

   • 5% lidocaine patches applied to affected areas for up to 12-24 hours
   • 4% over-the-counter or 5% prescription strength available
   • Provides gradual pain relief over hours with minimal systemic effects
   • Can be applied to dorsal or plantar surfaces, up to 3 patches at once 1
   • Advantage: Quick acting (immediate) but limited duration (1-2 hours) 2

2. Capsaicin

   • High-concentration capsaicin (8%) patches for postherpetic neuralgia
   • Apply for 30-minute sessions, repeatable every 3 months
   • May cause initial burning/stinging sensation
   • Desensitizes pain receptors through TRPV1 inhibition 1
   • Note: Lower concentrations (0.025%-0.075%) may be less effective

Second-Line Topical Options

1. Topical NSAIDs

   • Diclofenac 1% gel shows strong evidence for pain relief 1
   • Apply 3-4 times daily to affected areas
   • Minimal systemic absorption compared to oral NSAIDs
   • Particularly effective for localized pain 3, 2

2. Compounded analgesic preparations

   • Combinations may provide extended relief (2-3 applications daily)
   • Effective combinations include:
     • Amitriptyline-ketamine in vehicle base
     • Ketamine 10%, bupivacaine 1%, diclofenac 3%, doxepin 3%, gabapentin 6% 2
   • Requires compounding pharmacy

Application Recommendations

• Apply topicals to intact skin only (avoid open lesions)
• For lidocaine patches: clean and dry the area before application
• For capsaicin: warn patients about initial burning sensation
• Consider combining with oral antivirals for comprehensive treatment
• Apply moisturizing agents between medication applications to prevent cracking of crusted lesions 4

Important Considerations

• Timing is critical: Start treatment at earliest signs of shingles
• Age considerations: Older adults may be more sensitive to side effects
• Duration: Continue topical treatment until pain resolves
• Monitoring: Watch for skin irritation or allergic reactions
• Combination therapy: Topical treatments work best alongside systemic antivirals

When to Consider Systemic Options

• If pain is severe or widespread across multiple dermatomes
• When topical treatments provide inadequate relief
• For immunocompromised patients
• When postherpetic neuralgia develops

Treatment Algorithm

1. Acute phase (first 72 hours):

   • Start with lidocaine 5% patches/cream for immediate relief
   • Add oral antivirals (valacyclovir, famciclovir, or acyclovir)

2. Vesicular/crusting phase:

   • Continue lidocaine for pain control
   • Add capsaicin if lidocaine provides insufficient relief
   • Maintain moisture with white soft paraffin between medication applications 4

3. Healing phase:

   • Continue topical pain management as needed
   • Consider compounded preparations for persistent pain

4. Postherpetic neuralgia:

   • High-concentration capsaicin patches
   • Compounded analgesic preparations
   • Consider referral for nerve blocks if topical treatments fail

Remember that early intervention with appropriate topical agents can significantly reduce the risk of developing postherpetic neuralgia, which is more difficult to treat than acute shingles pain.