What is the treatment for postherpetic neuralgia (PHN)?

From the Guidelines

Postherpetic neuralgia (PHN) treatment typically involves the use of tricyclic antidepressants, certain opioids, gabapentin, pregabalin, and topical lidocaine patches.

First-Line Treatment Options

• Tricyclic antidepressants have been shown to be effective in treating PHN, with a number needed to treat (NNT) of 2.64 1.
• Gabapentin and pregabalin are also commonly used to treat PHN, with NNTs of 4.39 and 4.93, respectively 1.
• Topical lidocaine patches have been found to be effective in treating PHN, with an NNT of 2 1.

Second-Line Treatment Options

• Opioids, such as oxycodone and morphine, may be considered for patients who do not respond to first-line treatments, with an NNT of 2.67 1.
• Combination therapy, such as the use of gabapentin and opioids, may also be effective in treating PHN 1.

Important Considerations

• Patient response to treatment may vary, and clinicians should consider individual patient factors when selecting a treatment regimen.
• Potential side effects of medications, such as anticholinergic effects of tricyclic antidepressants, should be carefully considered, especially in older adults 1.
• Combination therapy may be beneficial for patients who do not respond to single medications, but may also increase the risk of adverse effects 1.

From the Research

Treatment Options for Postherpetic Neuralgia (PHN)

The treatment of PHN is often suboptimal, with less than half of patients achieving adequate 50% pain relief 2. The current management strategies for PHN include:

• Multidisciplinary and multimodal treatment approaches 2
• Pharmacologic management, such as:
  • Tricyclic antidepressants (e.g., amitriptyline, nortriptyline) 3, 4, 5
  • Anticonvulsants (e.g., gabapentin, pregabalin, carbamazepine) 3, 4, 5
  • Topical analgesics (e.g., 5% lidocaine patch, capsaicin) 3, 4, 5
  • Opioids (e.g., tramadol) 3, 4, 5
• Sympathetic nerve blocks, which can be used in conjunction with pharmacological treatment 6

Considerations for Treatment

The treatment of PHN should be tailored to the individual patient's response, as the side effect profiles of commonly used oral medications can limit their practical use 5. A combination of both topical and systemic agents may be required for optimal outcomes 5. Additionally, advances in sensory phenotyping technology and genomics may allow for more individualized treatment approaches 2.

Prevention of PHN

Prevention of PHN can be achieved through prompt recognition and treatment of high-risk herpes zoster (HZ) patients with antiviral and analgesic therapies 3. Vaccines, such as the Varicella Zoster (VZV) vaccine, also offer a promising approach to preventing HZ and PHN 2, 3.