Clinical Scenario

This protocol targets herpes zoster-associated neuropathic pain — specifically acute herpes zoster neuralgia — in patients whose pain has not been reduced to a tolerable level with prior systemic analgesic therapy.

Previous Treatment — Escalation Trigger

The preceding step involved tricyclic antidepressants (amitriptyline, nortriptyline, desipramine, or maprotiline). This protocol applies when that therapy failed to bring pain down to a level tolerable for the patient, as measured on a validated scale (VAS or NRS, 0–10).

Next-Step Approach — Partial Overview

When systemic therapy has not reached the pain target, a topical approach for localized pain becomes the next option — relevant once skin lesions have healed. The specific agents, their recommended sequence, and the complete clinical algorithm are in the full protocol below.

The treatment goal remains pain reduction to a level tolerable for the patient, assessed on a validated intensity scale (VAS or NRS, 0–10).

References

DOI: 10.1111/ddg.14013

In case of protopathic/neuropathic pain, additional treatment with incremental doses of gabapentin or pregabalin (antiepileptic agents) is recommended; if necessary, this may be combined with an antidepressant (for example, amitriptyline).
In such cases, it may be recommended to add tricyclic antidepressants (for example, amitriptyline); in case of localized pain and after the skin lesions have healed, capsaicin or lidocaine patches may be recommended.
Based on Cochrane reviews and given the lack of high-quality studies, lidocaine 5 % patches cannot be recommended as first-line pain medication for postherpetic neuralgia or neuropathic pain in general. However, as studies do provide evidence for a certain degree of pain relief, the expert panel recommends lidocaine patches as second-line treatment after capsaicin.
The treatment goal with respect to herpes zoster-associated pain should be optimal pain relief or at least pain reduction down to a level tolerable for the patient.

View source ↗

Acute Herpes Zoster Neuralgia: Next-Step Management When Tricyclic Antidepressants Did Not Achieve Adequate Pain Relief

References