Postherpetic neuralgia - Revision history

Rossdonaldson1: /* Disposition */

2025-01-29T22:49:56Z

Disposition

← Older revision		Revision as of 22:49, 29 January 2025
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	==Disposition==		==Disposition==
	Usually discharge home with pain management as described above		*Usually discharge home with pain management as described above.

	==See Also==		==See Also==

Rossdonaldson1: /* Management */

2025-01-29T22:49:34Z

Management

← Older revision		Revision as of 22:49, 29 January 2025
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	''Given that the pain is often difficult to control, much of the management will occur in a primary care setting, and will often involve trials and titration of multiple agents.''		''Given that the pain is often difficult to control, much of the management will occur in a primary care setting, and will often involve trials and titration of multiple agents.''

	~~In the~~ ED setting~~, consider:~~		===ED setting===
	*Gabapentinoid, either [[Pregabalin]] or [[Gabapentin]]		*Gabapentinoid, either [[Pregabalin]] or [[Gabapentin]]
	*[[Lidocaine]] 5% patch		*[[Lidocaine]] 5% patch
			*For short term relief of acute pain exacerbation:
			**[[Ketamine]] infusion
			**IV [[lidocaine]] infusion

	~~For short term relief of acute pain exacerbation:~~		===Primary Care Setting===
	*~~[[Ketamine]] infusion~~		*Tricyclic antidepressants (TCA)
	*~~Cardiac [[lidocaine]] infusions~~		*Topical capsaicin

	Invasive		'''Invasive'''
	*Sympathetic blockage		*Sympathetic blockage
	*Spinal stimulators		*Spinal stimulators

	~~Primary Care Setting:~~
	*Tricyclic antidepressants (TCA)
	*Topical Capsaicin

	==Disposition==		==Disposition==

Rossdonaldson1: /* Management */

2025-01-29T22:47:53Z

Management

← Older revision		Revision as of 22:47, 29 January 2025
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	==Management==		==Management==
	Given that ~~PHN~~ pain is often difficult to control, much of the management will occur in a primary care setting, and will often involve trials and titration of multiple agents.		''Given that the pain is often difficult to control, much of the management will occur in a primary care setting, and will often involve trials and titration of multiple agents.''
	In an ED setting, ~~initiating~~:
	*Gabapentinoid, either Pregabalin or Gabapentin		In the ED setting, consider:
	*Lidocaine 5% patch		*Gabapentinoid, either [[Pregabalin]] or [[Gabapentin]]
			*[[Lidocaine]] 5% patch

	For short term relief of acute pain exacerbation:		For short term relief of acute pain exacerbation:
	*Ketamine infusion		*[[Ketamine]] infusion
	*Cardiac lidocaine infusions		*Cardiac [[lidocaine]] infusions

	Invasive		Invasive
	*Sympathetic blockage		*Sympathetic blockage
	*Spinal stimulators		*Spinal stimulators

	Primary Care Setting:		Primary Care Setting:
	*Tricyclic antidepressants (TCA)		*Tricyclic antidepressants (TCA)

Rossdonaldson1: /* Evaluation */

2025-01-29T22:46:29Z

Evaluation

← Older revision		Revision as of 22:46, 29 January 2025
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	==Evaluation==		==Evaluation==
	~~The diagnosis is clinical and based on reported or evident recent acute zoster plus ongoing symptoms.~~

	===Workup===		===Workup===
	If other differentials are considered, workup would be tailored to confirming or ruling out those ~~differentials.~~		*Typically, none
			**If other differentials are considered, workup would be tailored to confirming or ruling out those processes

	===Diagnosis===		===Diagnosis===
			*Typically a clinical diagnosis based on recent acute zoster plus ongoing symptoms.

	==Prevention==		==Prevention==
	Treating shingles with antiviral therapy within 72 hours of rash appearance plays an important role in preventing the development of PHN. For immunocompromised patients, antiviral therapy should be initiated even after 72 hours.		Treating shingles with antiviral therapy within 72 hours of rash appearance plays an important role in preventing the development of PHN. For immunocompromised patients, antiviral therapy should be initiated even after 72 hours.

Rossdonaldson1: /* Differential Diagnosis */

2025-01-29T21:51:36Z

Differential Diagnosis

← Older revision		Revision as of 21:51, 29 January 2025
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	==Differential Diagnosis==		==Differential Diagnosis==
	*Acute zoster pain (see [[Shingles)]]		*Acute zoster pain (see [[Shingles]])
	*[[Focal neurologic deficits\|Other neuralgias and neuropathies (trigeminal, diabetic)]]		*[[Focal neurologic deficits\|Other neuralgias and neuropathies (trigeminal, diabetic)]]
	*Other causes of chest wall pain (e.g., [[rib injury]])		*Other causes of chest wall pain (e.g., [[rib injury]])
	*Pleuritic [[chest pain]] (p[[~~ulmonary~~ embolism]], [[pneumothorax]],[[ pneumonia]])		*Pleuritic [[chest pain]] ([[pulmonary embolism]], [[pneumothorax]],[[ pneumonia]])

	==Evaluation==		==Evaluation==

Rossdonaldson1: /* Differential Diagnosis */

2025-01-29T21:51:10Z

Differential Diagnosis

← Older revision		Revision as of 21:51, 29 January 2025
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	==Differential Diagnosis==		==Differential Diagnosis==
	*Acute ~~Zoster Pain~~		*Acute zoster pain (see [[Shingles)]]
	*[[Focal neurologic deficits\|Other neuralgias and neuropathies (trigeminal, diabetic)]]		*[[Focal neurologic deficits\|Other neuralgias and neuropathies (trigeminal, diabetic)]]
	*Other causes of chest wall pain (rib injury,		*Other causes of chest wall pain (e.g., [[rib injury]])
	*Pleuritic chest pain (~~pulmonary~~ embolism, pneumothorax, pneumonia)		*Pleuritic [[chest pain]] (p[[ulmonary embolism]], [[pneumothorax]],[[ pneumonia]])

	==Evaluation==		==Evaluation==

Rossdonaldson1: /* Differential Diagnosis */

2025-01-29T21:50:06Z

Differential Diagnosis

← Older revision		Revision as of 21:50, 29 January 2025
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	==Differential Diagnosis==		==Differential Diagnosis==
	*Acute Zoster Pain		*Acute Zoster Pain
	*Other neuralgias and neuropathies (trigeminal, diabetic)		*[[Focal neurologic deficits\|Other neuralgias and neuropathies (trigeminal, diabetic)]]
	*Other causes of chest wall pain (rib injury,		*Other causes of chest wall pain (rib injury,
	*Pleuritic chest pain (pulmonary embolism, pneumothorax, pneumonia)		*Pleuritic chest pain (pulmonary embolism, pneumothorax, pneumonia)

Rossdonaldson1: /* Clinical Features */

2025-01-29T19:11:23Z

Clinical Features

← Older revision		Revision as of 19:11, 29 January 2025
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	==Clinical Features==		==Clinical Features==
	*Pain in the same unilateral dermatomal distribution of a recent shingles episode which becomes more severe after the vesicular phase of shingles		*Pain in the same unilateral dermatomal distribution of a recent [[shingles]] episode which becomes more severe after the vesicular phase of shingles
	*Lancinating or burning pain which persists beyond 3 months after the shingles episode		*Lancinating or burning pain which persists beyond 3 months after the [[shingles]] episode
	*Scars may be evident from recent shingles		*Scars may be evident from recent [[shingles]]
	*Hypersensitivity, hypoesthesia, hyperalgesia or allodynia in the area.		*Hypersensitivity, hypoesthesia, hyperalgesia or allodynia in the area.
	*Autonomic dysfunction in the area (e.g. excessive sweating)		*Autonomic dysfunction in the area (e.g. excessive sweating)

Rossdonaldson1: /* Background */

2025-01-29T19:10:55Z

Background

← Older revision		Revision as of 19:10, 29 January 2025
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	[[File:Dermatoms alt.png\|thumb\|Sensory dermatomes by spinal level.]]		[[File:Dermatoms alt.png\|thumb\|Sensory dermatomes by spinal level.]]
	*Postherpetic neuralgia (PHN) is a complication of [[acute herpes zoster]] (AHZ), also known as "[[Shingles]]"		*Postherpetic neuralgia (PHN) is a complication of [[acute herpes zoster]] (AHZ), also known as "[[Shingles]]"
	*While [[AHZ]] is usually painful, PHN refers to pain which becomes severe and persists after the vesicular lesions of [[AHZ]] are no longer forming. There is an overlap between acute zoster pain and PHN pain, and together they are sometimes referred to as Zoster Associated Pain. However, if pain persists beyond 3 months from time of vesicle formation it is ~~now~~ termed PHN.		*While [[AHZ]] is usually painful, PHN refers to pain which becomes severe and persists after the vesicular lesions of [[AHZ]] are no longer forming. There is an overlap between acute zoster pain and PHN pain, and together they are sometimes referred to as Zoster Associated Pain. However, if pain persists beyond 3 months from time of vesicle formation it is termed PHN.
	*PHN can be challenging to treat, and may require trials and titration of various therapies, usually in a primary care or neurology outpatient setting.		*PHN can be challenging to treat, and may require trials and titration of various therapies, usually in a primary care or neurology outpatient setting.
	*Prevention of PHN by early antiviral therapy for ~~shingles~~ is a cornerstone of ED management		*Prevention of PHN by early antiviral therapy for [[AHZ]] is a cornerstone of ED management
	*Prevention of shingles via childhood varicella vaccination and adult shingles vaccination, in a primary care setting is the single most important preventing step		*Prevention of shingles via childhood [[varicella]] vaccination and adult shingles vaccination, in a primary care setting is the single most important preventing step

	==Clinical Features==		==Clinical Features==

Rossdonaldson1: /* Background */

2025-01-29T19:09:23Z

Background

← Older revision		Revision as of 19:09, 29 January 2025
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	==Background==		==Background==
	[[File:Dermatoms alt.png\|thumb\|Sensory dermatomes by spinal level.]]		[[File:Dermatoms alt.png\|thumb\|Sensory dermatomes by spinal level.]]
	*Postherpetic ~~Neuralgia~~ (PHN) is a complication of ~~Acute Herpes Zoster~~ (AHZ) (Shingles)		*Postherpetic neuralgia (PHN) is a complication of [[acute herpes zoster]] (AHZ), also known as "[[Shingles]]"
	*While ~~shingles~~ is usually painful, PHN refers to pain which becomes severe and persists after the vesicular lesions of AHZ are no longer forming. There is an overlap between acute zoster pain and PHN pain, and together they are sometimes referred to as Zoster Associated Pain. However, if pain persists beyond 3 months from time of vesicle formation it is now termed PHN.		*While [[AHZ]] is usually painful, PHN refers to pain which becomes severe and persists after the vesicular lesions of [[AHZ]] are no longer forming. There is an overlap between acute zoster pain and PHN pain, and together they are sometimes referred to as Zoster Associated Pain. However, if pain persists beyond 3 months from time of vesicle formation it is now termed PHN.
	*PHN can be challenging to treat, and may require trials and titration of various therapies, usually in a primary care or neurology outpatient setting.		*PHN can be challenging to treat, and may require trials and titration of various therapies, usually in a primary care or neurology outpatient setting.
	*Prevention of PHN by early antiviral therapy for shingles is a cornerstone of ED management		*Prevention of PHN by early antiviral therapy for shingles is a cornerstone of ED management