A 51-year-old male presents with pain in his left back for 3 months following herpes zoster infection. The doctor diagnoses the patient with postherpetic neuralgia (PHN) based on the dermatomal distribution of pain lasting over 90 days after the rash. PHN is characterized by neuropathic pain such as burning, shooting, and tingling sensations. The doctor discusses management options for PHN including tricyclic antidepressants, anticonvulsants like gabapentin and pregabalin, topical lidocaine patches, opioids, and combination therapies. Prevention through herpes zoster vaccination and prompt antiviral treatment for herpes zoster can help reduce the risk of PHN.

1. Budiarsana Foundation
@sukedanapt
Treatment for Chronic Pain
(Postherpetic Neuralgia/PHN)
dr Putu Sukedana S.Ked

2. DREAM
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Our home until 2017 -
- Our dreams comes true 2018

3.  Male, 51 years old, feeling pain at left back. 3 month ago become Herpes
zoster at site pain now. He felt burning at that place, what is your diagnose?
Management?
Case
1. Saguil, Aaron; Kane, Shawn; Mercado, Michael; Lauters, Rebecca. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. American Family Physician. 2017;96 (10): 656-663
2. Angkasa, F; Putra, IB; Yosi, A. 2020. Correlation between postherpetic neuralgia (PHN) patients stress level and the quality of life of their families in Universitas umatera Utara Hospital. Bali Me
dical Journal 9 (3): 749-752
@sukedanapt

4. 1
2
3
4
What is Postherpetic Neuralgia/PHN?
Epidemiology Postherpetic Neuralgia/PHN
Patophysiology
Management
@sukedanapt

5.  Pain in a dermatomal distribution that is sustained for at least 90 days after
the rash1
 Characterized neuropathic type pain: sharp and distinct. Quality pain :
burning, shooting and tingling sensation or worse, allodynia, and
hyperalgesia2
Postherpetic Neuralgia/PHN
1. Saguil, Aaron; Kane, Shawn; Mercado, Michael; Lauters, Rebecca. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. American Family Physician. 2017;96 (10): 656-663
2. Angkasa, F; Putra, IB; Yosi, A. 2020. Correlation between postherpetic neuralgia (PHN) patients stress level and the quality of life of their families in Universitas umatera Utara Hospital. Bali Me
dical Journal 9 (3): 749-752
@sukedanapt

6. @sukedanapt

7.  Approximately 20% of patients with herpes zoster and 80% of cases occur in
patients 50 years or older.1
 Herpes Zoster/HZ estimated in Asia Pacific: 3-10/1000 person/year.
Incidence of PHN is 10%-25%3
 Studied from 13 teaching hospitals in Indonesia, 26,5% patient become PHN
(593 patients from 2.232 cases). From studied of 30 PHN patients, 9 patients
(30%) mild stress, 16 patients (53.3%) experienced moderate stress; 5
patients (16,7%) severe stress levels2
Epidemiology Postherpetic Neuralgia/PHN
1. Saguil, Aaron; Kane, Shawn; Mercado, Michael; Lauters, Rebecca. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. American Family Physician. 2017;96 (10): 656-663
2. Angkasa, F; Putra, IB; Yosi, A. 2020. Correlation between postherpetic neuralgia (PHN) patients stress level and the quality of life of their families in Universitas umatera Utara Hospital. Bali Me
dical Journal 9 (3): 749-752
3. Shrestha, Meera; Chen, Aijun. Modalities in managing postherpetic neuralgia. Korean J Pain 2018 October; Vol. 31, No 4
@sukedanapt

8. Patophysiology of Herpes Zoster (HZ)
After the primary VZV infection (chickenpox), l
atent infection is established in the sensory-cr
anial nerve and spinal dorsal root ganglia1,2,3
The trigeminal and thoracic ganglia are the mo
st common neuronal sites involved; these der
matomes are also the most common sites of c
utaneous herpes zoster.
1. Kimberlin, David W; Whitley, Richard J. Varicella-Zoster Vaccine for the Prevention of Herpes Zoster. The New England Journal of Medicine 2007; 356: 1338-1343
2. Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multi
diciplinary Healthcare 2016:9 447-454
3. Nalamachu, Srinivas; Forster, Patricia Morley. Diagnosis and Managing Postherpetic Neuralgia. Drugs Aging. 2012; 29(11): 863–869
@sukedanapt

9. @sukedanapt

10. Management Chronic Pain1
 Pharmacology
Treatment
First Line: Tricyclic antidepressant,
Anticonvulsant or topical lidocaine 5% patches
Second or third line: Opioid, NSID, Steroid
OR COMBINATION
 Non Pharmacology
Treatment
Nerve block, Stimulation,
Physioterapy, Psycology
 Preventing chronic pain by more aggressive treatment of acute pain, avoid infection with VZV, and
prompt treatment of HZ with oral antiviral agents1,2
 61.1% reduction of HZ burden illness following vaccination compare than placebo2. HZ vaccine
decrease the incidence of PHN versus placebo approximately two-thirds3
1. Gwinnutt, Carl L. 2004. Lecture Notes Clinical Anaesthesia. Second Edition. UK: Blackwell Publishing
2. Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multidiciplinary Healthc
are 2016:9 447-454
3. Nalamachu, Srinivas; Forster, Patricia Morley. Diagnosis and Managing Postherpetic Neuralgia. Drugs Aging. 2012; 29(11): 863–869
@sukedanapt

11. Tricyclic antidepressant
Amitriptyline1
Mechanism through inhibit of serotonine and noradrenaline
reuptake at CNS1,2 and blocking voltage-dependent sodium cha
nnels and α-adrenergic receptors, actions important in modulatin
g descending pain pathways5
NNT 2.5. Pain relieve
25%-50% of patient
than placebo2,5.
1. Gwinnutt, Carl L. 2004. Lecture Notes Clinical Anaesthesia. Second Edition. UK: Blackwell Publishing
2. R Andrew, Moore; Sheena, Derry; Dominic, Aldington; Peter Cole, Wiffen. Amitriptyline for neuropathic pain in adults (Review). Cochrane Database of Systematic Reviews 2015, Issues 7.
3. Mounsey, Anne L; Matthew, Leah G; Slawson, David C. Herpes Zooster and Postherpetic Neuralgia: Prevention and Management. American Family Physician: September 15, 2005. Volume 72 Number 6
4. Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multidiciplinary Healthcare 2016:9 447-454
5. Nalamachu, Srinivas; Forster, Patricia Morley. Diagnosis and Managing Postherpetic Neuralgia. Drugs Aging. 2012; 29(11): 863–869
 Available as tablet 10,25,50 m
g oral, usually take it at night2
 Side effect is anticholinergic a
ctivity include dry mouth, weig
ht gain, conctipation and drow
siness 2,3
 Dose started12,5-25 mg daily2
,3. Increased 12,5-25 mg every
three to five days.3 Maximum
dose 250 mg daily.3
 Caution in the elderly with hea
rt desease, epilepsy or glauco
ma4
@sukedanapt

12. Sumber: Obata, Hide
aki. Analgesic Mechan
isms of Antidepressan
ts for Neuropathic Pai
n. Internationa Journal
of Molecular Sciences.
2017,18, 2483
@sukedanapt

13. Anticonvulsants
Gabapentin &
Pregabalin
 Gabapentin: dose started 300-600 mg orally three times per
day1 Taper dose over seven days when discontinuing therapy,
Maximum dose 3.600 mg/day2
 Adverse effect: Dizziness, peripheral edema, sedation, weight
gain, dry mouth, constipation1,2
 Pregabalin: dose started 150-300 mg orally per day in two or
three divided doses. Maximum dose 600 mg.day. Adverse effe
ct same like Gabapentin1,2
1. Saguil, Aaron; Kane, Shawn; Mercado, Michael; Lauters, Rebecca. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. American Family Physician. 2017;96 (10): 656-663
2. Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multidiciplinary Healthcare 2
6:9 447-454
3. Nalamachu, Srinivas; Forster, Patricia Morley. Diagnosis and Managing Postherpetic Neuralgia. Drugs Aging. 2012; 29(11): 863–869
 Mechanism through calcium chanel 𝛼2-𝛿ligands2 : voltage-gated calcium channel blockers, inhibiting central pain pathways3
 In the Cochrane Database of Systematic Reviews, the NNT to obtain a patient with a 50 % reduction in pain was 7.5 for gabapenti
n and 5.0–11 for pregabalin 300–600 mg3
@sukedanapt

14. Hayashida, Ken-ichiro; Obata, Hideaki. Strategies to Treat Chronic Pain and Strengthen Impaired Descening Noradrenergic Inhibitory System. International Journal of Molecular
Sciences. 2018, 20, 822
@sukedanapt

15. Fentanyl
Patch
• Apply at skin and replace every 3 days. Popular because
avoid needles. Reduced side effect compare morphine1
Lidocaine
5% Patch
• Lidocaine blocks voltage-gated sodium
channels3 Lidocaine 5% patches has
been shown both in clinical practice and
improved quality of life and 66% reduced
pain2. NNT 2.0-4.43
• Apply every 4-12 hours, up to three
patches per day2
1. Gwinnutt, Carl L. 2004. Lecture Notes Clinical Anaesthesia. Second Edition. UK: Blackwell Publishing
2. Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multidiciplinary Healthcar
e 2016:9 447-454
3. Nalamachu, Srinivas; Forster, Patricia Morley. Diagnosis and Managing Postherpetic Neuralgia. Drugs Aging. 2012; 29(11): 863–869
@sukedanapt

16. Tramadol
• Tramadol provided significant pain relief in patients with PHN
(NNT 4-5)1 Starting dose at 50 mg one or two times per day;
titrated in 50-100 mg increments in devided doses every 3-7
days. Maximum dosage 400 mg/day2 Adverse reactions:
Dizziness, nausea, constipation, headache, somnolen,
flushing, pruritus, vomiting, insomnia, dry mouth, diarrhea,
sweating, anorexia, postural hypotension
Morphine
• Commonly used (oral/IV). Dose:10-
15 mg every 4 hours. Side effect:
Sedation, but can minimalize by
titration2,3 NNT 2.74
OPIOD
1. Saguil, Aaron; Kane, Shawn; Mercado, Michael; Lauters, Rebecca. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. American Family Physician. 2017;96 (10): 656-663
2. Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multidiciplinary Healthcare 2016:9 447-454
3. Gwinnutt, Carl L. 2004. Lecture Notes Clinical Anaesthesia. Second Edition. UK: Blackwell Publishing
4. Nalamachu, Srinivas; Forster, Patricia Morley. Diagnosis and Managing Postherpetic Neuralgia. Drugs Aging. 2012; 29(11): 863–869
@sukedanapt

17. Combination Therapy
Lidocaine 5 % topical patch in combination
with systemic agent such as pregabalin1
Systemic agents combinations such as gaba
pentin/nortriptyline or morphine/gabapentin1
First Option
Second Option
1. Nalamachu, Srinivas; Forster, Patricia Morley. Diagnosis and Managing Postherpetic Neuralgia. Drugs Aging. 2012; 29(11): 863–869
@sukedanapt

18. Thank you
 Almighty God
 Dedication to: Alm Wayan Budiarsana, my family for their support
 My teachers from elementary until medical faculty
 My senior who share their experienced to treat patients with PHN
 This slides still needs to be improved. If there is any input/opinion, we are welcome
with that