Post-herpetic neuralgia
A shingles rash heals in two to four weeks, but in some people the pain in the same place stays on after the skin has healed.
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Medicines commonly prescribed for Post-herpetic neuralgia
For informational purposes only. Always consult a doctor before using any medicine.
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A shingles rash heals in two to four weeks, but in some people the pain in the same place stays on after the skin has healed. That lingering pain is called post-herpetic neuralgia. It is not a skin complication and not the rash coming back: what is damaged is the nerve the virus travelled along. The pain is real even when there is nothing left to see, which is exactly why it tends to be underestimated, both by the people around and by the person living with it. For most people it fades with time, and in the meantime it can and should be treated.
What it feels like and how long it lasts
The pain sits in exactly the band of skin where the rash was: usually on one side, most often on the chest, back or flank, less often on the forehead and around the eye. It comes in different forms, and several often occur in the same person:
- a constant burning or aching pain, as though the skin had been scalded;
- sudden shooting pains like an electric shock;
- pain from things that should not hurt at all — a bedsheet, the elastic of underwear, a breeze, cool water in the shower;
- an unbearable itch that leads to scratching the skin raw;
- numbness and reduced feeling in the same area, sometimes right next to the painful part.
The skin there may stay paler or darker, with small scars. Those are marks left by the rash, not a sign that the illness is still going on.
The pain interferes with sleeping, dressing and working, it wears people down and often flattens the mood; low spirits and anxiety alongside it are part of the picture, not a weakness of character. It usually eases gradually: many people are clearly better within a few months and most within the year. In some, isolated sensations last longer, but even then they can be made bearable.
Post-herpetic neuralgia is the term used when the pain is still there around three months after the rash appeared. Occasionally it does not start straight away: the rash clears, there is a quiet interval, and then the pain returns.
Why the pain stays, and who is more likely to get it
The chickenpox virus does not disappear after the childhood illness: it stays in the nerve ganglia. When immunity dips it wakes up, travels along a nerve to the skin and causes shingles. On the way it damages the nerve itself and its ganglion. A damaged nerve starts sending pain signals to the brain for no reason at all, and a touch that used to register as touch is now read as pain.
There is no way to predict in advance who this will happen to, but it is more likely:
- with age — it is rare before fifty and common after seventy;
- if the rash was heavy and covered a large area;
- if the pain during the acute phase was severe;
- if pain or burning began even before the rash;
- if the eye or forehead was involved;
- with diabetes and with conditions that weaken immunity.
Post-herpetic neuralgia itself is not infectious: the virus is passed on from the blisters while the rash is fresh, and once there is no rash there is nothing to pass on.
What else can hurt like this
There is no test that confirms this condition. The diagnosis rests on the history: there was shingles, the pain stayed in the same place, and on examination the skin in that band hurts to a light touch. Neither blood tests nor scans show post-herpetic neuralgia; they are arranged when the picture does not fit and something else has to be ruled out.
It is worth checking further if the pain behaves differently from what is expected:
- a new rash has appeared — this may be another episode of shingles, treated with antiviral medicines rather than painkillers;
- the pain is somewhere else, not where the rash was, and should not be put down to the neuralgia;
- chest pain with breathlessness, sweating and spread to the arm or jaw — that is how heart disease behaves, not neuralgia;
- pain in the flank with fever, vomiting or a change in the urine — the kidney or gallbladder needs looking at;
- pain running down an arm or leg with weakness and numbness — more often a nerve root trapped by a spinal problem;
- brief stabbing attacks in the face triggered by chewing, shaving or brushing the teeth — that is the pattern of trigeminal neuralgia.
When help is needed urgently
See a doctor the same day if:
- the rash or pain involves the forehead, eyelid or nose, especially with blisters on the tip of the nose: it means the branch of the nerve running to the eye is affected and an eye assessment is needed;
- you develop eye pain, redness, discomfort in bright light or reduced vision;
- one side of the face becomes weak, the mouth droops, or you get ear pain, hearing loss, ringing or vertigo;
- the skin around the healed rash turns red and hot, with pus and a temperature;
- the rash comes back or spreads over the body while you are taking medicines that suppress the immune system;
- the pain becomes unbearable, you have gone several nights without sleep, or you cannot eat or drink.
Call an ambulance — 112 is the single emergency number across much of Europe — if you develop a severe headache with a stiff neck and fever, confusion, seizures or sudden loss of vision, and also if chest pain comes with breathlessness or a feeling of tightness.
How it is treated
Nerve pain works differently from the pain of an injury or inflammation, so different medicines are needed. Ordinary painkillers and anti-inflammatories do little for it, and non-steroidal anti-inflammatory drugs are poorly tolerated in later life, since they affect the stomach, the kidneys and blood pressure. Paracetamol may take the edge off, but relying on it alone is not realistic.
The mainstay is medicines that act on how pain travels along the nerve:
- anti-epileptic medicines such as gabapentin and pregabalin;
- antidepressants used for their pain-relieving effect, such as amitriptyline and duloxetine; they are prescribed to damp down pain, not because the pain is "in the mind";
- a lidocaine plaster applied to the painful patch, which acts locally and is particularly useful when the touch of clothing is unbearable;
- capsaicin cream or patch, which increases the burning at first but then reduces the skin's sensitivity;
- opioid painkillers such as tramadol or codeine, only as a short course and only when other options have not worked: they cause drowsiness, constipation and dependence.
One medicine is often not enough, and doctors commonly combine an oral one with a topical one. If the pain will not settle, people are referred to a pain clinic, where stronger patches, nerve blocks and psychological pain management are used; the last of these teaches ways of coping with long-term pain and noticeably improves sleep and daily life.
What to know about nerve pain medicines
These medicines do not work like a headache tablet, and misunderstanding that is why many people abandon them in the first few days.
They always start at a low dose that is increased gradually over weeks. A clear effect usually arrives after two to four weeks, so "it did nothing in two days" means nothing yet.
Drowsiness, dizziness, a dry mouth, swollen ankles and blurred vision are common at the start. In an older person that also means a risk of falling, so the first doses are taken at night and it is worth getting out of bed slowly. Driving is best avoided until the dose is settled.
These medicines must not be stopped suddenly, neither the anti-epileptics nor the antidepressants. An abrupt stop causes anxiety, insomnia, sweating and nausea, and sometimes the pain returns worse than before. If a medicine does not suit you, your doctor will set out a plan for coming off it gradually.
Always mention every other medicine you take and any kidney problems: both the choice of drug and the dose depend on them. Alcohol adds to the drowsiness and dizziness.
What you can do yourself
Medicines do not remove the pain entirely, and what you do at home adds noticeably to the result.
- Wear loose cotton or silk clothing; wool and tight seams over the area are usually intolerable.
- Cover the sensitive patch with a soft dressing under your clothes: it takes the edge off the fabric brushing against it.
- Apply something cool wrapped in a towel for ten to twenty minutes, if cold helps you.
- Do not use a hot water bottle or heat the area strongly: feeling there is reduced and a burn can go unnoticed.
- Do not scratch; keep your nails short, and if the itch is unbearable ask your doctor about treatments that calm it.
- Keep a short pain diary: it shows whether a treatment is working and makes the conversation at the appointment easier.
- Do not give up your usual activities and walks altogether: being immobile and isolated makes pain worse.
- Look after your sleep: pain and insomnia feed each other, and breaking that cycle matters more than it seems.
How to reduce the risk in future
Post-herpetic neuralgia is easier to prevent than to treat, and two measures genuinely work.
The first is starting shingles treatment as early as possible. Antiviral medicines work better the sooner they are begun, and the greatest benefit comes within the first three days of the rash appearing. So sudden one-sided pain with blisters is a reason to be seen without delay. Good pain relief during the acute phase also lowers the chance of the pain dragging on.
The second is the shingles vaccine. It reduces both the chance of getting shingles and the chance of prolonged pain afterwards. It is recommended for older adults and for people whose immunity is weakened by illness or treatment; the exact age, the type of vaccine and the number of doses differ between countries, so check your national immunisation schedule or ask a doctor. Having had shingles does not rule out vaccination — a past episode does not protect against another one.
Anything that lowers the chance of the virus reactivating helps too: controlling blood sugar in diabetes, treating the underlying condition, and sleeping and recovering properly after periods of heavy strain.
Online consultation
Pain after shingles drags on for months, and much of the work is adjusting the dose, judging the effect and deciding what to change next. Those conversations work well online: a doctor can weigh up whether your pain fits post-herpetic neuralgia, explain what to expect from the prescribed medicine and by when, help you make sense of side effects and say when it is time for a pain clinic. Prevention is worth discussing online too — vaccination and what to do at the next episode. But if the eye is involved, the face has drooped, there is a fever or a new rash has appeared, you need to be examined in person the same day, and with confusion or a severe headache you need an ambulance.
This material is for information only and does not replace medical advice.
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