12093 Postherpetic Neuralgia

Overview

Postherpetic neuralgia (PHN) is a long-lasting nerve pain that continues in the area of a shingles rash after the rash has healed. It happens when the virus that causes chickenpox damages the nerve fibres, leaving them overactive and sending pain signals to the brain even when there is no new rash or tissue damage.

It is fairly common. Around 1 in 5 people who have had shingles will develop postherpetic neuralgia. The risk increases with age.

PHN most often affects adults over 60, people with weakened immune systems, and people who had a severe shingles rash. It is rare in children and young adults.

Symptoms

Common symptoms

• Burning, throbbing, or stabbing pain in the area where the shingles rash once was
• Pain that lasts for weeks, months, or even years after the rash has healed
• Extreme sensitivity to light touch — even clothing or a breeze can trigger pain
• Itching, tingling, or a feeling of numbness in the affected area
• Weakness or muscle aches around the affected area
• Sleep problems because of the pain

Symptoms in children

• PHN is very rare in children, but if it happens, symptoms may include mild pain, tingling, or sensitivity in the area of a past shingles rash.
• Children usually recover faster and have less severe pain than adults.

Symptoms in older adults

• Pain is usually more intense and lasts longer than in younger people.
• The affected skin may be very sensitive, making everyday activities like dressing and bathing uncomfortable.
• Older adults are more likely to experience chronic fatigue, low mood, and trouble sleeping due to persistent pain.

Causes

Main causes

• Shingles is caused by the varicella-zoster virus — the same virus that causes chickenpox.
• After a chickenpox infection, the virus stays asleep in nerve tissue, often for many years.
• When the virus wakes up, it travels down the nerve fibres to the skin, causing the painful shingles rash.
• The virus damages the nerve endings and the surrounding nerve pathways, leaving them irritated and overactive.
• Even after the skin rash heals, the nerves continue to send false pain signals to the brain. This is what causes postherpetic neuralgia.

Risk factors

• Age: being over 60 is the strongest risk factor.
• Having a severe shingles rash or pain before the rash appears.
• Having shingles on the face or trunk; facial shingles, especially near the eye, carries a higher risk of nerve pain.
• Having a weakened immune system due to illness, treatments such as chemotherapy, or medications that suppress the immune system.
• Experiencing significant pain during the acute shingles phase also makes PHN more likely.

When to see a doctor

See a doctor urgently if:

• See a doctor the same day if you are in the middle of a shingles flare-up and are at high risk of complications — for example, if you are older than 50, have a weakened immune system, or the rash is near your eye or on your face.
• Get same-day medical help if your pain is severe, continues to worsen after the rash has healed, or stops you from doing normal daily activities.

Book a routine appointment if:

• Make a routine appointment if the pain lasts for more than 3 months after the rash has gone, or if it is affecting your sleep, mood, or ability to work.
• Also see your doctor if you would like to explore medicines, nerve blocks, or other treatments to manage the pain.
• Ask your doctor for advice if you are finding it hard to cope with the emotional side of living with chronic pain.

Diagnosis

There is no single test for postherpetic neuralgia. A doctor will take a detailed history and examine the area of the previous shingles rash. If you have had a shingles rash in the same location and the pain has lasted for at least 3 months after healing, the diagnosis is usually clear.

Tests that may be done

• Your doctor will ask about your symptoms, how long you have had the pain, and how it affects your life.
• They will examine your skin to look for scars, marks, or colour changes from the previous rash.
• Sometimes a skin swab is taken if there is a new rash or if there is any doubt about an active shingles infection.
• If your doctor suspects an underlying cause of nerve pain, such as diabetes or vitamin deficiency, they may recommend a blood test. But for typical postherpetic neuralgia, no blood test is needed.

What to expect at your appointment

The doctor will usually start by listening to your experience and asking you to describe the pain in your own words. They may gently touch the skin with a cotton pad or a soft brush to check sensitivity. The physical examination is usually quick and should not cause lasting discomfort. You will leave with a clear explanation of the diagnosis and a plan for managing the pain.

Treatment

The main goals are to reduce pain, improve sleep, and help you return to your usual activities. Starting treatment early — within weeks of the rash — can make a difference, but even long-standing PHN can improve with the right approach. Your doctor will create a plan tailored to you, which may include self-care strategies, medications, non-drug interventions, and sometimes referral to a pain clinic or specialist.

Self-care at home

• Apply a cold pack (wrapped in a towel) to the painful area for 10–15 minutes a few times a day — but wait until the rash has healed completely.
• Wear loose-fitting clothing made from natural fabrics like cotton to reduce friction and sensitivity.
• Protect the area with a soft dressing or a shield of breathable adhesive tape if it hurts to touch.
• Keep the skin clean and moisturised – avoid harsh soaps and perfumed products.
• Distract yourself with activities you enjoy – focusing on hobbies, socialising, or gentle movement can sometimes ease the experience of pain.
• Try relaxation techniques such as slow breathing, mindfulness, or progressive muscle relaxation.

Medical treatments

Your healthcare provider may suggest medications that are used for nerve pain. These are generally started at a low dose and increased gradually to find the right balance between pain relief and side effects. For many people, a regular schedule of pain medication works better than taking it only when the pain spikes. The doctor may also consider topical pain-relieving patches or creams, or a procedure called a nerve block — an injection near the affected nerves that interrupts pain signals. Always ask your doctor or pharmacist to explain the expected benefits, side effects, and how long you may need to take any treatment. Do not stop or start any medication without talking to a qualified healthcare professional.

When is surgery considered?

Surgery is very rarely needed for postherpetic neuralgia. In a small number of people who do not respond to other treatments, a pain specialist may offer a procedure such as spinal cord stimulation — a device that sends gentle electrical pulses to change how the nervous system perceives pain. This is an option to discuss with a specialist centre, but it is not a first-line treatment.

Living with this condition

Living with PHN can be physically draining and emotionally wearing. It may help to accept that recovery can be gradual. Set small, realistic goals for daily activities and pace yourself. Keep your regular routine as much as possible, and let your family and friends know how you are feeling so they can support you. Using a pain diary can also help you and your doctor see what makes the pain better or worse.

Lifestyle tips

• Get enough sleep: pain often feels worse when you are tired, so aim for a consistent sleep schedule.
• Gentle exercise such as walking, swimming, or stretching can improve blood flow and help keep your joints and muscles flexible.
• Try to reduce stress – stress makes pain feel worse. Pick one or two calming activities you enjoy and do them regularly.
• Stay socially connected: isolation can make pain feel more intense, so keep in touch with friends, family, or a support group.
• Avoid smoking and limit alcohol, as both can interfere with nerve health and sleep.

Diet and exercise

A healthy, balanced diet helps your body repair nerves and keeps your immune system strong. Include plenty of fruits, vegetables, wholegrains, and lean proteins. If you drink alcohol, do so in moderation — alcohol and some pain medications do not mix well. For exercise, start slowly. A short, gentle walk most days is better than aggressive workouts. Movement can help maintain muscle strength and may distract you from pain, but stop if you feel severe discomfort.

Mental health and emotional wellbeing

Living with chronic pain can cause stress, anxiety, poor sleep, and low mood. It is completely normal to feel frustrated or sad. If these feelings last for more than a few weeks or start to affect your daily life, speak with your GP — talking therapy, such as counselling or cognitive behavioural therapy, can be very helpful for people with long-term pain. If you are ever having thoughts about self-harm or suicide, please contact your local crisis service immediately or go to the nearest emergency department.

Prevention

The most effective way to prevent postherpetic neuralgia is to prevent shingles in the first place. In the UK and many other countries, a safe and effective shingles vaccine is offered to adults aged 50 and older, and to people with weakened immune systems. If you have never had chickenpox, getting vaccinated against chickenpox can also reduce your risk. If you already have shingles, seeing a doctor within 72 hours of the rash appearing and starting recommended treatment may lower the chance of developing PHN.

Vaccines

Ask your GP or local pharmacy about the shingles vaccine. In the UK, the vaccine is available free on the NHS to people aged 50 and over and to those with a weakened immune system. Even if you have already had shingles, you can still have the vaccine to protect against future flare-ups.

Screening programmes

There is no routine screening test for postherpetic neuralgia. If you have had shingles, your GP can assess your risk and suggest early management to reduce the chance of long-term pain.

Complications

If left untreated

• Long-term nerve pain that is not managed can lead to depression, anxiety, and social withdrawal.
• Severe pain can affect sleep, which lowers your quality of life and makes health problems harder to cope with.
• Rarely, shingles near the eye can cause vision problems, so it is important to get medical help early for facial shingles.
• Untreated PHN may also make you less active, and this can lead to muscle weakness or poor fitness over time.

Long-term outlook

The outlook for postherpetic neuralgia is generally positive. The pain improves on its own in many people within the first year, and treatments work in a large proportion of people. It can take time and patience, and you may need to try different approaches, but most people find significant relief. You are not alone — with the right support, most people return to their normal routines and a good quality of life.

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