What it is

➝ Postherpetic neuralgia (PHN) is the most common complication of herpes zoster (shingles), characterized by persistent nerve pain lasting more than 90 days after the rash heals.

➝ The pain can be burning, stabbing, or shooting, and may be accompanied by tingling, numbness, or allodynia (pain from light touch).

➝ Prevention strategies aim to reduce the risk, severity, and duration of PHN by intervening early during the acute herpes zoster episode.

➝ In Korea, prevention involves a multimodal approach combining antivirals, early pain control, and long-term preventive measures such as vaccination.

Why it’s done

→ To lower the incidence of PHN, which significantly impacts quality of life, especially in older adults.

→ To prevent chronic pain syndromes, which can cause insomnia, depression, and reduced daily functioning.

→ To reduce healthcare costs and hospitalizations related to prolonged pain management.

→ In Korea, PHN prevention is a key clinical priority, given the country’s aging population.

Alternatives

→ Antiviral therapy: Acyclovir, valacyclovir, famciclovir started within 72 hours of rash onset.

→ Aggressive pain management during acute zoster: NSAIDs, opioids, gabapentinoids, TCAs, or nerve blocks.

→ Corticosteroids: Sometimes used short-term with antivirals to reduce inflammation and acute pain, though evidence on PHN prevention is mixed.

→ Vaccination (Shingrix): Prevents herpes zoster and significantly lowers PHN risk.

Preparation

→ Early clinical diagnosis of herpes zoster is essential. The sooner antivirals and pain management are started, the better the preventive effect.

→ Patients are evaluated for risk factors: age over 50, severe acute pain, extensive rash, ophthalmic involvement, or immunocompromised status.

→ In Korea, baseline screening includes renal and hepatic function tests if antivirals or certain pain medications are prescribed.

How it’s Done

→ Step 1: Early antiviral therapy

• Acyclovir, valacyclovir, or famciclovir started within 72 hours of rash onset.
• Reduces viral replication, speeds healing, and lowers nerve damage risk.

→ Step 2: Acute pain control

• NSAIDs or acetaminophen for mild pain.
• Opioids for severe pain.
• Gabapentin or pregabalin started early in patients with severe acute nerve pain to lower PHN risk.
• Tricyclic antidepressants (amitriptyline, nortriptyline) sometimes used in high-risk patients.

→ Step 3: Interventional pain therapy (if needed)

• Nerve blocks with local anesthetics or steroids to reduce acute pain and prevent chronic sensitization.
• Epidural injections in select severe cases.

→ Step 4: Skin and wound care

• Preventing secondary infections reduces prolonged inflammation that can worsen nerve damage.

→ Step 5: Long-term prevention

• Herpes zoster vaccination (Shingrix) in adults over 50 or immunocompromised patients.
• Prevents reactivation and lowers PHN incidence dramatically.

Recovery

→ Patients treated with antivirals and good pain control typically experience faster rash healing in 2–4 weeks.

→ PHN prevention strategies reduce the risk of chronic pain developing beyond 3 months.

→ Early gabapentinoid or nerve block use in severe cases improves nerve healing and pain thresholds.

→ Vaccinated individuals show significantly lower recurrence and complication rates.

Complications

→ Without prevention, up to 20–30% of herpes zoster patients over age 60 may develop PHN.

→ Uncontrolled acute pain is the strongest predictor of PHN.

→ Medication risks:

• Antivirals: headache, nausea, renal strain.
• Gabapentin/pregabalin: dizziness, sedation.
• TCAs: dry mouth, constipation, cardiac effects in elderly.

→ With preventive strategies, most patients tolerate therapy well and avoid chronic complications.

Treatment Options in Korea

→ Korean clinics emphasize early diagnosis and treatment initiation, with same-day antiviral prescriptions standard practice.

→ Pain management programs are often multidisciplinary, involving dermatologists, neurologists, and pain specialists.

→ Gabapentin or pregabalin are frequently prescribed early in severe cases to prevent PHN progression.

→ Some centers use nerve blocks or epidural injections as part of early interventional pain therapy.

→ Preventive vaccination with Shingrix is actively promoted in Korea for older adults, with growing public uptake.

→ Overall, Korea’s PHN prevention combines early antiviral therapy, aggressive pain control, and long-term vaccination strategy, reducing the burden of this debilitating complication.