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Postherpetic Neuralgia (postherpetic + neuralgia)

Distribution by Scientific Domains

Medical Sciences	95%

Distribution within Medical Sciences

Dermatology	44%
Neurology	20%

Selected Abstracts

Peripheral Nerve Stimulation in Treatment of Intractable Postherpetic Neuralgia

NEUROMODULATION, Issue 4 2007
Alexander E. Yakovlev MD
ABSTRACT Objective., This case report presents an application of peripheral nerve stimulation to a patient with intractable postherpetic neuralgia that conventional treatment failed to ameliorate. Methods., The patient underwent an uneventful peripheral nerve stimulator trial with placement of two temporal eight-electrode percutaneous leads (Octrode leads, Advanced Neuromodulation Systems, Plano, TX, USA) into the right subscapular and right paraspinal area of the upper thoracic region. Results., Upon experiencing excellent pain relief over the next two weeks, the patient underwent implantation of permanent leads two weeks later and reported sustained pain relief. Conclusion. Peripheral nerve stimulation offers an alternative treatment option for intractable pain associated with postherpetic neuralgia, especially for elderly patients where treatment options are limited due to existing comorbidities. Further studies are warranted. [source]

An Integrative Approach for Treating Postherpetic Neuralgia,A Case Report

PAIN PRACTICE, Issue 3 2007
Shu-Ming Wang MD
Abstract: This report describes the successful treatment of a patient with postherpetic neuralgia using traditional pharmacology in combination with acupuncture. Case Report: A 13-year-old girl developed postherpetic neuralgia following a severe attack of varicella zoster. Despite a 1-week course of intravenous acyclovir initiated at the onset of symptoms, the patient developed persistent left facial pain and constant nausea after lesions were healed. A comprehensive pain treatment regimen, consisting of a stellate ganglia block, medications, transcutaneous electrical nerve stimulation and hypnosis, was administered, but the patient did not gain any incremental pain relief. The acupuncture service was consulted to provide assistance with this patient's pain management. A combination of body and auricular acupuncture as well as related techniques, including acupressure and transcutaneous acupoint electrical stimulation, was added to the pain treatment regimen. After 10 complementary acupuncture treatments over a 2-month period, the patient's nausea disappeared. Her left facial pain continued to decline from a maximum of 10 to 0 as assessed by a visual analog scale over a period of 4 months following self-administered treatments of acupressure and transcutaneous acupoint electrical stimulation. The patient was then gradually weaned off all her medications and the complementary acupuncture treatment. She was discharged from the pediatric pain clinic after 5 months of the combined therapy. Conclusions: Acupuncture and its related techniques may be an effective adjunctive treatment for symptoms associated with postherpetic neuralgia and deserve further study. [source]

Adjuvant topical therapy with a cannabinoid receptor agonist in facial postherpetic neuralgia

JOURNAL DER DEUTSCHEN DERMATOLOGISCHEN GESELLSCHAFT, Issue 2 2010
Ngoc Quan Phan
Summary Background: Postherpetic neuralgia is a frequent adverse event in herpes zoster patients and difficult to treat. Conventional analgetic therapy often fails to reduce the burning pain transmitted by unmyelinated nerve fibers. These nerves express cannabinoid receptors which exert a role in modulation of nociceptive symptoms. Therefore, topical therapy with cannabinoid receptor agonist seems likely to suppress local burning pain. Patients and methods: In an open-labeled trial, 8 patients with facial postherpetic neuralgia received a cream containing the cannabinoid receptor agonist N-palmitoylethanolamine. The course of symptoms was scored with the visual analog scale. Results: 5 of 8 patients (62.5 %) experienced a mean pain reduction of 87.8 %. Therapy was tolerated by all patients. No unpleasant sensations or adverse events occurred. Conclusions: Topical cannabinoid receptor agonists are an effective and well-tolerated adjuvant therapy option in postherpetic neuralgia. [source]

Broad-band ultraviolet B phototherapy in zoster patients may reduce the incidence and severity of postherpetic neuralgia

PHOTODERMATOLOGY, PHOTOIMMUNOLOGY & PHOTOMEDICINE, Issue 5 2006
Mir Hadi Aziz Jalali
Background: Postherpetic neuralgia (PHN) is one of the common complications of herpes zoster infection, particularly in the elderly. Current therapeutic measures are only partially effective in the affected patients. As inflammatory mediators released by different cells play an important role in the pathogenesis of this neuropathic pain and with regard to the immunomodulatory effects of ultraviolet B (UVB) spectrum, we presumed that UVB phototherapy might be effective in the prevention of PHN. Method: This study was performed in two phases. Phase I was a prospective open controlled trial. Twenty-five patients with severe pain in the first 7 days of zoster rash were divided into two groups: the prevention group (n=12) received oral acyclovir (800 mg five times a day for 10 days) plus broad-band UVB to the affected dermatomes, starting with 20 mJ/cm2 and gradually increasing the dose by 10 mJ/cm2 each session to a maximum dose of 100 mJ/cm2. Treatment sessions were repeated three times a week until pain relief or to a maximum of 15 sessions. The control group (n=13), who had disease characteristics similar to the prevention group, received only oral acyclovir with the same dose. All patients reported their severity of pain on a verbal rating scale (VRS, score 0,4) before treatment and at 1 and 3 months' follow-up. In phase II of the study, five patients with established PHN (more than 3 months after rash onset) received UVB with the above-mentioned protocol. Results: A total of 17 patients older than 40 (10 females, seven males; mean age, 65.5 years; range: 47,82 years) who had intractable pain due to zoster infection received UVB in two phases of the study. In patients who received phototherapy in the first 7 days of rash, 58.33% and 83.33% were completely pain free at 1-and 3-month follow-up, respectively. The corresponding figure in the control group was significantly lower (38.46% at 1 month and 53.85% at 3 months). The severity of pain was also lower in the phototherapy group than the control group (mean VRS 2.50 vs. 3.28 at 3 months). None of the patients who were treated more than 3 months after rash onset (established PHN) experienced significant (more than 50%) pain relief. Conclusion: UVB phototherapy in the acute stage of zoster rash might reduce the incidence and severity of PHN. Treatment after 3 months does not seem to have a significant beneficial effect. [source]

Cutaneous infections in the elderly: diagnosis and management

DERMATOLOGIC THERAPY, Issue 3 2003
Jeffrey M. Weinberg
ABSTRACT:, Over the past several years there have been many advances in the diagnosis and treatment of cutaneous infectious diseases. This review focuses on the three major topics of interest in the geriatric population: herpes zoster and postherpetic neuralgia (PHN), onychomycosis, and recent advances in antibacterial therapy. Herpes zoster in adults is caused by reactivation of the varicella-zoster virus (VZV) that causes chickenpox in children. For many years acyclovir was the gold standard of antiviral therapy for the treatment of patients with herpes zoster. Famciclovir and valacyclovir, newer antivirals for herpes zoster, offer less frequent dosing. PHN refers to pain lasting ,2 months after an acute attack of herpes zoster. The pain may be constant or intermittent and may occur spontaneously or be caused by seemingly innocuous stimuli such as a light touch. Treatment of established PHN through pharmacologic and nonpharmacologic therapy will be discussed. In addition, therapeutic strategies to prevent PHN will be reviewed. These include the use of oral corticosteroids, nerve blocks, and treatment with standard antiviral therapy. Onychomycosis, or tinea unguium, is caused by dermatophytes in the majority of cases, but can also be caused by Candida and nondermatophyte molds. Onychomycosis is found more frequently in the elderly and in more males than females. There are four types of onychomycosis: distal subungual onychomycosis, proximal subungual onychomycosis, white superficial onychomycosis, and candidal onychomycosis. Over the past several years, new treatments for this disorder have emerged which offer shorter courses of therapy and greater efficacy than previous therapies. The treatment of bacterial skin and skin structure infections in the elderly is an important issue. There has been an alarming increase in the incidence of gram-positive infections, including resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and drug-resistant pneumococci. While vancomycin has been considered the drug of last defense against gram-positive multidrug-resistant bacteria, the late 1980s saw an increase in vancomycin-resistant bacteria, including vancomycin-resistant enterococci (VRE). More recently, strains of vancomycin-intermediate resistant S. aureus (VISA) have been isolated. Gram-positive bacteria, such as S. aureus and Streptococcus pyogenes are often the cause of skin and skin structure infections, ranging from mild pyodermas to complicated infections including postsurgical wound infections, severe carbunculosis, and erysipelas. With limited treatment options, it has become critical to identify antibiotics with novel mechanisms of activity. Several new drugs have emerged as possible therapeutic alternatives, including linezolid and quinupristin/dalfopristin. [source]

Treatment of varicella-zoster virus and postherpetic neuralgia

DERMATOLOGIC THERAPY, Issue 3 2000
Daniel A. Carrasco
ABSTRACT: Chickenpox is mostly a disease of childhood; shingles usually affects the elderly, but any age group may be afflicted. Although several proved pharmacologic agents are known to be efficacious in the acute phase of varicella-zoster infections, only three are FDA approved for use in immunocompetent zoster patients and one for the use in primary varicella infections. Ongoing studies with immunocompromised patients are determining whether higher doses of newer oral antivirals will be effective. While a cure for postherpetic neuralgia has not been found, effective treatment to reduce its duration and severity means early implementation of newer antiviral agents. While corticosteroids do not prevent postherpetic neuralgia, they do improve the quality of life when used in combination with acyclovir. Often, symptomatic relief with narcotics, topical anesthetics, and tricyclic antidepressants are necessary. [source]

EFNS guidelines on pharmacological treatment of neuropathic pain

EUROPEAN JOURNAL OF NEUROLOGY, Issue 11 2006
N. Attal
Neuropathic pain treatment remains unsatisfactory despite a substantial increase in the number of trials. This EFNS Task Force aimed at evaluating the existing evidence about the pharmacological treatment of neuropathic pain. Studies were identified using first the Cochrane Database then Medline. Trials were classified according to the aetiological condition. All class I and II controlled trials (according to EFNS classification of evidence) were assessed, but lower-class studies were considered in conditions that had no top level studies. Only treatments feasible in an outpatient setting were evaluated. Effects on pain symptoms/signs, quality of life and comorbidities were particularly searched for. Most of the randomized controlled trials included patients with postherpetic neuralgia (PHN) and painful polyneuropathies (PPN) mainly caused by diabetes. These trials provide level A evidence for the efficacy of tricyclic antidepressants, gabapentin, pregabalin and opioids, with a large number of class I trials, followed by topical lidocaine (in PHN) and the newer antidepressants venlafaxine and duloxetine (in PPN). A small number of controlled trials were performed in central pain, trigeminal neuralgia, other peripheral neuropathic pain states and multiple-aetiology neuropathic pains. The main peripheral pain conditions respond similarly well to tricyclic antidepressants, gabapentin, and pregabalin, but some conditions, such as HIV-associated polyneuropathy, are more refractory. There are too few studies on central pain, combination therapy, and head-to-head comparison. For future trials, we recommend to assess quality of life and pain symptoms or signs with standardized tools. [source]

Adjuvant topical therapy with a cannabinoid receptor agonist in facial postherpetic neuralgia

Healthcare Costs of Acute and Chronic Pain Associated with a Diagnosis of Herpes Zoster

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2007
Robert H. Dworkin PhD
OBJECTIVES: To determine the healthcare costs of acute and chronic pain associated with herpes zoster. DESIGN: Retrospective cohort analysis. SETTING: Inpatient and outpatient care. PARTICIPANTS: Patients were selected from Medicare, commercial insurance, and Medicaid claims databases if they had a diagnosis of herpes zoster or postherpetic neuralgia (PHN) or were prescribed analgesics after a diagnosis of herpes zoster (possible PHN) and were matched to controls for demographic and clinical factors using propensity scores. MEASUREMENTS: One-year excess healthcare expenditures attributable to herpes zoster pain or PHN were calculated for inpatient, outpatient, and prescription drug services. RESULTS: For the Medicare cohort, the average excess cost per patient was $1,300 in the year after a diagnosis of herpes zoster with 30 days or fewer of analgesic use and ranged from $2,200 to $2,300 per patient with PHN or possible PHN. Patients with possible PHN were 53% more prevalent than patients with PHN in the Medicare cohort and accounted for half of all excess expenditures. Findings were similar in the younger cohorts with commercial insurance and Medicaid except that costs attributable to PHN and possible PHN were higher, and patients with possible PHN were three to five times as prevalent as patients with PHN. CONCLUSION: Healthcare costs associated with PHN were substantially greater than those associated with herpes zoster pain that resolved within 30 days. The data suggest that as many as 80% of patients with PHN may not be diagnosed with PHN and that these patients account for at least half of PHN expenditures. [source]

Varicella-zoster virus isolates, but not the vaccine strain OKA, induce sensitivity to alpha-1 and beta-1 adrenergic stimulation of sensory neurones in culture

JOURNAL OF MEDICAL VIROLOGY, Issue S1 2003
Michaela Schmidt
Abstract The reactivation of varicella-zoster virus (VZV) from its persistent state in sensory neurones causes shingles and induces severe, long-lasting pain and hyperalgesia that often lead to postherpetic neuralgia. To investigate the VZV-induced neuropathic changes, we established conditions for the active infection of sensory neurones from rat dorsal root ganglia in vitro. After 2 days of culture, up to 50% of the cells expressed viral antigens of the immediate-early and late replication phase. The intracellular calcium ion concentration was monitored in individual cells by microfluorimetry. Whereas the calcium response to capsaicin was preserved, the VZV-infected neurones gained an unusual sensitivity to noradrenaline stimulation in contrast to non-infected cells. The adrenergic agonists phenylephrine and isoproterenol had a similar efficacy demonstrating that both ,1 - and ,1 -adrenoreceptors were involved. The sensitivity to adrenergic stimulation was observed after infection with different wildtype isolates, but not with the attenuated vaccine strain OKA. The lack of noradrenaline sensitivity of vaccine-infected neurones demands a structural comparison of wildtype and vaccine viruses with and without phenotype. A partial sequence evaluation (26 kb) of the European OKA vaccine strain surprisingly revealed a series of nucleotide exchanges in comparison to presumably identical OKA strains from other sources, although VZV is generally considered genetically stable. In summary, we report that the infection with wildtype VZV isolates, but not with the vaccine strain, induces noradrenaline sensitivity in sensory neurones, which correlates with clinical and experimental observations of adrenergic effects involved in VZV-induced neuralgia. J. Med. Virol. 70:S82,S89, 2003. © 2003 Wiley-Liss, Inc. [source]

Peripheral Nerve Stimulation in Treatment of Intractable Postherpetic Neuralgia

Herpes zoster in HIV infection with osteonecrosis of the jaw and tooth exfoliation

ORAL DISEASES, Issue 5 2006
P Siwamogstham
Background:, Herpes zoster (HZ) infection of the trigeminal nerve is associated with complications such as postherpetic neuralgia, facial scarring, loss of hearing ability and conjunctivitis. Until 2005, postherpetic alveolar necrosis and spontaneous tooth exfoliation have been described in 20 cases unrelated to HIV infection. Objective:, The aim of this study was to describe HIV infection in patients (two women, two men, average age 30 years) who suffered from HZ attacks to their trigeminal nerves. Main outcome measures:, None of the patients had received antiherpetic medications or antiretroviral therapy. HIV infection was only diagnosed after the development of HZ. Facial scarring with depigmentation and hyperesthesia (postherpetic neuralgia) was diagnosed in all four patients. Oral findings consisted of spontaneous loss of both maxillary or mandibular teeth. Osteonecrosis of varying extent was also found. Treatment consisted of extractions of teeth and administration of antibiotics and analgesics. Healing of alveolar wounds was unremarkable. Conclusion:, Complications affecting the alveolar bone and teeth seem to be rare in HIV-infected patients. [source]

Opioids and the Management of Chronic Severe Pain in the Elderly: Consensus Statement of an International Expert Panel with Focus on the Six Clinically Most Often Used World Health Organization step III Opioids (Buprenorphine, Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone)

PAIN PRACTICE, Issue 4 2008
Joseph Pergolizzi MD
,,Abstract Summary of consensus: 1.,The use of opioids in cancer pain:, The criteria for selecting analgesics for pain treatment in the elderly include, but are not limited to, overall efficacy, overall side-effect profile, onset of action, drug interactions, abuse potential, and practical issues, such as cost and availability of the drug, as well as the severity and type of pain (nociceptive, acute/chronic, etc.). At any given time, the order of choice in the decision-making process can change. This consensus is based on evidence-based literature (extended data are not included and chronic, extended-release opioids are not covered). There are various driving factors relating to prescribing medication, including availability of the compound and cost, which may, at times, be the main driving factor. The transdermal formulation of buprenorphine is available in most European countries, particularly those with high opioid usage, with the exception of France; however, the availability of the sublingual formulation of buprenorphine in Europe is limited, as it is marketed in only a few countries, including Germany and Belgium. The opioid patch is experimental at present in U.S.A. and the sublingual formulation has dispensing restrictions, therefore, its use is limited. It is evident that the population pyramid is upturned. Globally, there is going to be an older population that needs to be cared for in the future. This older population has expectations in life, in that a retiree is no longer an individual who decreases their lifestyle activities. The "baby-boomers" in their 60s and 70s are "baby zoomers"; they want to have a functional active lifestyle. They are willing to make trade-offs regarding treatment choices and understand that they may experience pain, providing that can have increased quality of life and functionality. Therefore, comorbidities,including cancer and noncancer pain, osteoarthritis, rheumatoid arthritis, and postherpetic neuralgia,and patient functional status need to be taken carefully into account when addressing pain in the elderly. World Health Organization step III opioids are the mainstay of pain treatment for cancer patients and morphine has been the most commonly used for decades. In general, high level evidence data (Ib or IIb) exist, although many studies have included only few patients. Based on these studies, all opioids are considered effective in cancer pain management (although parts of cancer pain are not or only partially opioid sensitive), but no well-designed specific studies in the elderly cancer patient are available. Of the 2 opioids that are available in transdermal formulation,fentanyl and buprenorphine,fentanyl is the most investigated, but based on the published data both seem to be effective, with low toxicity and good tolerability profiles, especially at low doses. 2.,The use of opioids in noncancer-related pain:, Evidence is growing that opioids are efficacious in noncancer pain (treatment data mostly level Ib or IIb), but need individual dose titration and consideration of the respective tolerability profiles. Again no specific studies in the elderly have been performed, but it can be concluded that opioids have shown efficacy in noncancer pain, which is often due to diseases typical for an elderly population. When it is not clear which drugs and which regimes are superior in terms of maintaining analgesic efficacy, the appropriate drug should be chosen based on safety and tolerability considerations. Evidence-based medicine, which has been incorporated into best clinical practice guidelines, should serve as a foundation for the decision-making processes in patient care; however, in practice, the art of medicine is realized when we individualize care to the patient. This strikes a balance between the evidence-based medicine and anecdotal experience. Factual recommendations and expert opinion both have a value when applying guidelines in clinical practice. 3.,The use of opioids in neuropathic pain:, The role of opioids in neuropathic pain has been under debate in the past but is nowadays more and more accepted; however, higher opioid doses are often needed for neuropathic pain than for nociceptive pain. Most of the treatment data are level II or III, and suggest that incorporation of opioids earlier on might be beneficial. Buprenorphine shows a distinct benefit in improving neuropathic pain symptoms, which is considered a result of its specific pharmacological profile. 4.,The use of opioids in elderly patients with impaired hepatic and renal function:, Functional impairment of excretory organs is common in the elderly, especially with respect to renal function. For all opioids except buprenorphine, half-life of the active drug and metabolites is increased in the elderly and in patients with renal dysfunction. It is, therefore, recommended that,except for buprenorphine,doses be reduced, a longer time interval be used between doses, and creatinine clearance be monitored. Thus, buprenorphine appears to be the top-line choice for opioid treatment in the elderly. 5.,Opioids and respiratory depression:, Respiratory depression is a significant threat for opioid-treated patients with underlying pulmonary condition or receiving concomitant central nervous system (CNS) drugs associated with hypoventilation. Not all opioids show equal effects on respiratory depression: buprenorphine is the only opioid demonstrating a ceiling for respiratory depression when used without other CNS depressants. The different features of opioids regarding respiratory effects should be considered when treating patients at risk for respiratory problems, therefore careful dosing must be maintained. 6.,Opioids and immunosuppression:, Age is related to a gradual decline in the immune system: immunosenescence, which is associated with increased morbidity and mortality from infectious diseases, autoimmune diseases, and cancer, and decreased efficacy of immunotherapy, such as vaccination. The clinical relevance of the immunosuppressant effects of opioids in the elderly is not fully understood, and pain itself may also cause immunosuppression. Providing adequate analgesia can be achieved without significant adverse events, opioids with minimal immunosuppressive characteristics should be used in the elderly. The immunosuppressive effects of most opioids are poorly described and this is one of the problems in assessing true effect of the opioid spectrum, but there is some indication that higher doses of opioids correlate with increased immunosuppressant effects. Taking into consideration all the very limited available evidence from preclinical and clinical work, buprenorphine can be recommended, while morphine and fentanyl cannot. 7.,Safety and tolerability profile of opioids:, The adverse event profile varies greatly between opioids. As the consequences of adverse events in the elderly can be serious, agents should be used that have a good tolerability profile (especially regarding CNS and gastrointestinal effects) and that are as safe as possible in overdose especially regarding effects on respiration. Slow dose titration helps to reduce the incidence of typical initial adverse events such as nausea and vomiting. Sustained release preparations, including transdermal formulations, increase patient compliance.,, [source]

An Integrative Approach for Treating Postherpetic Neuralgia,A Case Report

A Review of Sympathetically Maintained Pain Syndromes in the Cancer Pain Population:

PAIN PRACTICE, Issue 4 2001
The spectrum of ambiguous entities of RSD, other pain states related to the sympathetic nervous system
Abstract: Accepted wisdom contends that sympathetically maintained pain is rare in cancer pain syndromes. But this may be more of an artifact of how we diagnose this condition than a reflection of its true prevalence. One area in which one might suspect this to be true is in postsurgical states. While there are case reports of sympathetically maintained pain occurring after radical neck dissection, orbital and maxillary exenteration, it has not been reported in the more common areas of postsurgical pain. For instance, although one should suspect that the nerve damage that accompanies post-thoracotomy and postmastectomy pain syndromes would bring into being a certain incidence of sympathetically maintained pain, it is difficult to find collaborative reports. This may have more to do with the difficulty inherent in diagnosing sympathetically maintained pain than its actual contribution to these persistent cancer pain syndromes. The reason that it is more commonly reported in limb amputation is less comprehensible since blocking the sympathetic fibers that travel to an extremity is easier than those going to the thoracic cavity. In addition to surgically induced sympathetically maintained pain, medical patients with lymphoma and leukemia may have an element of sympathetically maintained pain when they develop postherpetic neuralgia. While the contribution of sympathetically maintained pain in these cases is not totally ignored, its involvement, as in the surgical patients mentioned above, is worthy of another analysis. This paper will discuss the topics introduced above and suggest diagnostic and therapeutic options available for this condition. [source]

Herpes zoster in older adults. (Duke University Medical Center, Durham, NC) Clinical Infectious Diseases.

PAIN PRACTICE, Issue 4 2001
1486., 2001;32:148
Herpes zoster (HZ) strikes millions of older adults annually worldwide and disables a substantial number of them via postherpetic neuralgia (PHN). Key aged-related clinical, epidemiological, and treatment features of zoster and PHN are reviewed in this article. HZ is caused by renewed replication and spread of the varicella-zoster virus (VZV) in sensory ganglia and afferent peripheral nerves in the setting of age-related, disease-related, and drug-related decline in cellular immunity to VZV. VZV-induced neuronal destruction and inflammation causes the principal problems of pain, interference with activities in daily living, and reduced quality of life in elderly patients. Recently, attempts to reduce or eliminate HZ pain have been bolstered by the findings of clinical trials that antiviral agents and corticosteroids are effective treatment for HZ and that tricyclic antidepressants, topical lidocaine, gabapentin, and opiates are effective treatment for PHN. Although these advances have helped, PHN remains a difficult condition to prevent and treat in many elderly patients. Comment by Miles Day, M.D. This article reviews the epidemiology clinical features diagnosis and treatment of acute herpes zoster. It also describes the treatment of postherpetic neuralgia. While this is a good review for the primary care physician, the discussion for the treatment for both acute herpes zoster and postherpetic neuralgia do not mention invasive therapy. It is well documented in pain literature that sympathetic blocks with local anesthetic and steroid as well as subcutaneous infiltration of active zoster lesions not only facilitate the healing of acute herpes zoster but also prevents or helps decrease the incidence of postherpetic neuralgia. All patients who present to the primary care physician with acute herpes zoster should have an immediate referral to a pain management physician for invasive therapy. The treatment of postherpetic neuralgia is a challenging experience both for the patient and the physician. While the treatments that have been discussed in this article are important, other treatments are also available. Regional nerve blocks including intercostal nerve blocks, root sleeve injections, and sympathetic blocks have been used in the past to treat postherpetic neuralgia. If these blocks are helpful, one can proceed with doing crynourlysis of the affected nerves or also radio-frequency lesioning. Spinal cord stimulation has also been used for those patients who are refractory to noninvasive and invasive therapy. While intrathecal methylprednisolone was shown to be effective in the study quoted in this article one must be cautious not to do multiple intrathecal steroid injections in these patients. Multilple intrathecal steroid injections can lead to archnoiditis secondary to the accumulation of the steroid on the nerve roots and in turn causing worsening pain. [source]