Postherpetic Neuralgia: Mechanisms, Risk Factors, and Stratified Management-A Narrative Review

AI Summary

Pathogenesis: viral reactivation, peripheral and central sensitisation, and genetic modulation drive persistent neuropathic pain.
Major risk factors: older age, severe acute pain, extensive rash, craniofacial or thoracic involvement, immunocompromise, comorbidities, and treatment delay.
Stratified management: Tier 1 pharmacotherapies and topical agents first line; Tier 2 interventional options; Tier 3 opioids and neuromodulation require cautious, individualised use.

AI Summary

Management strategies were tiered by guideline support, regulatory approval, and PHN-specific efficacy and safety evidence.

Management of PHN is tiered: Tier 1 treatments include gabapentinoids, the 5% lidocaine patch, tricyclic antidepressants, duloxetine, and the 8% capsaicin patch; Tier 2 treatments include botulinum toxin type A injections, pulsed radiofrequency, and temporary spinal cord stimulation (tSCS); and Tier 3 options include opioids and neuromodulation.

Although a stratified framework for PHN management has been proposed, it still requires validation in clinical practice and further refinement to support more effective individualized treatment.

Basic summary

CNS Neurosci Ther. 2026 Jul;32(7):e71002. doi: 10.1002/cns.71002.

ABSTRACT

BACKGROUND: In 2020, an estimated 14.9 million herpes zoster (HZ) cases occurred worldwide among adults aged ≥ 50 years; this number is projected to rise to 19.1 million by 2030. Postherpetic neuralgia (PHN), the most common complication of HZ, develops in 5% to > 30% of patients with HZ. Poorly managed PHN may cause persistent pain, functional impairment, psychological distress, and, in severe cases, suicide. This review summarizes the current evidence on PHN and proposes a tiered management framework.

METHODS: PubMed and Web of Science were searched for PHN-related articles published from January 2011 to December 2025, with reference-list screening. Studies were selected by clinical relevance and design. Management strategies were tiered by guideline support, regulatory approval, and PHN-specific efficacy and safety evidence.

RESULTS: Pathogenesis involves viral reactivation, peripheral and central sensitization, and genetic modulation. Major risk factors include older age, severe acute pain, extensive rash, craniofacial/thoracic involvement, immunocompromise, comorbidities, and treatment delay. Management of PHN is tiered: Tier 1 treatments include gabapentinoids, the 5% lidocaine patch, tricyclic antidepressants, duloxetine, and the 8% capsaicin patch; Tier 2 treatments include botulinum toxin type A injections, pulsed radiofrequency, and temporary spinal cord stimulation (tSCS); and Tier 3 options include opioids and neuromodulation.

CONCLUSIONS: PHN remains the most common and therapeutically challenging complication of HZ. Although a stratified framework for PHN management has been proposed, it still requires validation in clinical practice and further refinement to support more effective individualized treatment.

PMID:42377991 | DOI:10.1002/cns.71002

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