Acute pain associated with shingles (herpes zoster)

Acute pain associated with shingles (herpes zoster) may occur before, with or following the rash. It usually has neuropathic and nociceptive components. The pain can be severe, especially on the face. Antiviral treatment started within 72 hours accelerates pain resolution. In most cases, pain intensity diminishes gradually and resolves completely over a few weeks; however, the elderly are more likely to have severe or persistent pain.

If there is ocular involvement, consult an ophthalmologist; see Herpes zoster ophthalmicus for management advice.

Use the following pain management strategies to treat the neuropathic or nociceptive component. Management strategies may be combined if both components are present.

Neuropathic shingles pain can be treated with lidocaine 5% patches; however, they cannot be used on broken skin or lesions, which are common in the acute phase of infection.

Compared to oral therapy for neuropathic pain, lidocaine 5% patches have a lower rate of systemic adverse effects and drug interactions, which is especially useful for frail or elderly patients or patients taking multiple medications. If skin is intact, for neuropathic shingles pain, use:

Gabapentinoids may be used in addition to, or as an alternative to, lidocaine 5% patches; see Acute neuropathic pain for dose advice.

Mild nociceptive shingles pain can be treated with oral paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs); see Mild, acute nociceptive pain for dose advice. Ice packs and protective dressings may also provide relief.

Moderate to severe nociceptive shingles pain can be treated with an oral corticosteroid, in addition to oral paracetamol and NSAIDs. If complications of corticosteroid therapy are anticipated, they should be used with caution. Use:

Large studies have shown that pain resolves faster when prednisolone is used, especially when used in combination with aciclovir (the combination of prednisolone with famciclovir or valaciclovir is assumed to be equally effective). However, there is no evidence that systemic corticosteroids alone, or in combination with antiviral therapy, prevent postherpetic neuralgia or other neurological complications of shingles.

If oral paracetamol, NSAIDs and prednisolone are unlikely to provide adequate analgesia, add an oral opioid; tramadol and tapentadol may be especially useful if the pain is predominantly nociceptive but also has a neuropathic component. See Moderate, acute nociceptive pain and Severe, acute nociceptive pain for dose advice.

Continue treatment for nociceptive pain until the skin lesions have healed (approximately 7 to 10 days). Seek specialist advice if pain is refractory.