PONOS CLINIC · PAIN MEDICINE · TURIN
Post-herpetic neuralgia
The skin heals. The pain may remain.
Treatment options and when to consider pulsed radiofrequency after shingles.
Conceptual illustration; not a diagnostic or anatomical image.
What is post-herpetic neuralgia?
Post-herpetic neuralgia is persistent nerve pain following shingles. It may affect the chest, back, abdomen or limbs, as well as the face. Burning, shooting pain, itching and allodynia — pain from light touch or clothing — can interfere with sleep and daily activities. Duration varies.
Assessment: mapping the pain
Bring the date of the rash, photographs if available, details of antiviral treatment and a list of pain medicines tried, including benefit and adverse effects. The examination compares the previous rash with the painful area and assesses sensation and functional impact. New or different pain needs reassessment: not every symptom in the same area is caused by shingles.
Medicines and local treatments
Treatment may include medicines for neuropathic pain, such as selected antidepressants, gabapentin or pregabalin, and appropriate topical preparations such as lidocaine. Selection depends on the site, other conditions, concurrent medicines and tolerability. Topical products require suitable skin and specific instructions; they must not be applied to eyes, mucous membranes or open lesions.
Who may be considered for pulsed radiofrequency?
A procedure is considered after clinical assessment, rather than on pain duration alone. The assessment should establish:
- Diagnosis and distribution: agreement between the shingles territory, current pain and sensory findings, with other causes considered.
- Clinical impact: persistent pain, allodynia, disturbed sleep or restricted activities.
- Previous treatment: an inadequate response to appropriate care, or adverse effects limiting its use; medicines, tolerated doses and duration should be documented.
- Target and safety: an appropriate nerve or ganglion, acceptable procedural risk, realistic expectations and follow-up.
Infection at the proposed access site, uncorrected bleeding problems or an uncertain diagnosis may require postponement or a different plan. Not every patient needs to try every medicine before referral: treatment is individualised.
PRF is different from thermal radiofrequency
Pulsed radiofrequency aims to modulate nerve activity; it is not interchangeable with continuous radiofrequency used to produce a thermal lesion. In post-herpetic neuropathic pain, destructive techniques require a separate assessment. PRF is not routine treatment for every episode of shingles and does not guarantee permanent pain relief.
Dorsal root ganglion or intercostal nerve?
For thoracic shingles-related pain, both dorsal root ganglion (DRG) PRF and intercostal nerve PRF have been studied. The distribution of pain and the balance of procedural access, risks and potential benefit guide selection. Results from thoracic studies cannot automatically be extended to the neck or limbs.
A 2021 retrospective study compared 96 patients treated at the DRG with 83 treated at intercostal nerves. Both groups improved, with more favourable outcomes in the DRG group through 12 weeks. Participants were over 60 and had pain for more than one month, so the population was not restricted to established pain beyond three months. The observational design and short follow-up limit certainty.
When should treatment be considered?
Pain assessment can begin during acute shingles, alongside its medical management. Severe pain persisting over subsequent weeks warrants reassessment. There is no need to wait months before seeking help, but no universally established deadline for PRF. The studies cited do not justify a promise that PRF prevents chronic pain.
Safety and follow-up
Infection, coagulation, anticoagulants and general health are reviewed before a procedure. Do not stop medicines without advice. Potential risks include bleeding, infection and nerve injury; thoracic approaches also carry a risk of pneumothorax, while ganglion approaches require care around neighbouring spinal structures. Specific risks are discussed during consent.
Follow-up considers pain, sleep, tolerance of clothing, activities and medicine use. Partial relief can be useful, but repeat procedures or a change of strategy require reassessment.
Specialist assessment at PONOS Clinic
A consultation helps select treatment according to your symptoms and previous care.