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Postherpetic neuralgia

Zahid H Bajwa, MD
Erik Ortega, MD
Section Editor
Jeremy M Shefner, MD, PhD
Deputy Editor
John F Dashe, MD, PhD


Varicella-zoster virus (VZV) is the causative agent of varicella, or "chickenpox," and herpes zoster, or "shingles." Most cases of acute herpes zoster are self-limited, although the pain can cause significant suffering, particularly in older adults. Symptoms may be severe enough to interfere with sleep, appetite, or sexual function. In addition, a variable percentage of patients may continue to experience pain for months to years after the resolution of the rash, a condition known as postherpetic neuralgia (PHN). PHN can be quite difficult to treat.

The pathogenesis, epidemiology, clinical features, diagnosis, and treatment of PHN are reviewed here. Other aspects of the varicella-zoster virus and the acute therapy of herpes zoster infection are discussed separately. (See "Epidemiology and pathogenesis of varicella-zoster virus infection: Herpes zoster" and "Treatment of herpes zoster in the immunocompetent host".)


Acute herpes zoster is caused by reactivation of the varicella-zoster virus (VZV). The virus persists for a period of years in the dorsal root ganglia of cranial or spinal nerves after resolution of the original infection. As cellular immunity wanes with age or immunocompromise, the virus is transported along peripheral nerves, producing an acute neuritis [1,2].

At the cellular level, infection with acute herpes zoster is characterized by hemorrhagic inflammation of the peripheral nerve, dorsal root, and dorsal root ganglion. Extension centrally into the spinal cord and leptomeninges also has been described [3]. Fibrosis is noted in the dorsal root ganglion, nerve root, and peripheral nerve upon resolution of the acute process [4,5].

Autopsy data for cases of well-established PHN are limited. One study reported five cases, three with severe PHN and two with no persistent pain [6]. The findings included dorsal horn atrophy as well as cellular, axonal, and myelin loss with fibrosis in the sensory ganglion in patients with persistent pain. However, marked axonal and myelin loss in the nerve and/or sensory root were found in cases with and without pain.

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Literature review current through: Nov 2017. | This topic last updated: Feb 13, 2017.
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