Post-herpetic neuralgia – a review of current management and future directions

ABSTRACT

Introduction: Post-herpetic neuralgia (PHN) is common and treatment is often suboptimal with less than half of patients achieving adequate 50% pain relief. As an area of unmet clinical need and as an archetype of neuropathic pain, it deserves the attention of clinicians and researchers.

Areas covered: This review summarises the epidemiology, pathophysiology, risk factors and clinical features of varicella infection. It describes the current and possible future management strategies for preventing varicella infection and reactivation and for treating PHN.

Expert opinion: A highly successful Varicella Zoster (VZV) vaccine has not been universally adopted due to fears that it may increase Herpes Zoster (HZ) incidence – and thus PHN – in older, unvaccinated generations. This is a controversial theory but advances in the efficacy of vaccines against HZ may allay these fears and encourage more widespread adoption of the VZV vaccine.

Treatment of PHN, as for any neuropathic pain, must be multidisciplinary and multimodal. Advances in sensory phenotyping technology and genomics may allow more individualised treatment. Traditional research methodologies are ill-suited to assess the kind of complex interventions that are necessary to achieve better clinical outcomes in this challenging field.

KEYWORDS:

• Varicella
• herpes zoster
• post-herpetic
• neuropathic
• vaccination
• exogenous boosting
• pharmacotherapy
• sensory phenotype

Article highlights

• A comprehensive overview of post-herpetic neuralgia, including its pathogenesis and the strategies that currently exist and that are being explored to reduce its incidence and burden.

• Exploration of the contribution of vaccination to prevent PHN – and the attendant controversies.

• Description of current international guidelines – and their limitations – for management of post-herpetic management.

• A review of novel strategies, both preventative and therapeutic, for the management of post-herpetic neuralgia.

• An emphasis on the directing treatment to neuropathological mechanisms using phenotypic or genotypic stratification rather than aetiology.

• A call for a change in research strategy to address the complexities of neuropathic pain, using complex intervention methodology.

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Declaration of interest

P Farquhar-Smith has been remunerated for consultancy/education for Grunethal, Astellas Pharma and Pfizer. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was not funded.