Intended for healthcare professionals

Practice Best Practice

Herpes zoster infection

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k5095 (Published 10 January 2019) Cite this as: BMJ 2019;364:k5095

Re: Herpes zoster infection

The article on herpes zoster provides a useful practice update. However, the guidance on management approaches for Post-Herpetic Neuralgia (PHN) seems to be out of step with currently recommended practice. This is important as it is the commonest complication of herpes zoster (9-30% incidence) and can be the cause of considerable persisting pain and suffering. PHN is a classical neuropathic pain condition and if simple analgesics do not suffice (as will often be the case) then institution of anti-neuropathic pain medications rather than strong opioids should be the next step. This is in line with NICE guidance which advocates either a tricyclic antidepressant in low dose or a gabapentinoid as first line therapies (https://cks.nice.org.uk/post-herpetic-neuralgia). If these are unsuccessful and pain symptoms are persisting then a referral to a pain clinic for consideration of other treatment approaches such as topical capsaicin or combination therapies should be considered before or alongside the introduction of strong opioids. The evidence base supporting the use of strong opioids in PHN is relatively weak (as it is for most neuropathic pain) and the evidence of harms is increasingly apparent in the shape of the current prescription opioid crisis (see for example Godlee's editorial https://www.bmj.com/content/359/bmj.j4828).

Competing interests: No competing interests

12 January 2019
Anthony E Pickering
Anaesthetist & Pain Clinician
University Hospitals Bristol
University of Bristol