Shingles and postherpetic nerve pain

The rash of shingles usually heals within a few weeks. The pain sometimes does not. People who still have burning or aching skin long after the blisters have gone often wonder whether something is wrong or whether it will ever stop. That lingering pain has a name, postherpetic neuralgia, and it is the subject of this page. We cover why it happens, who is more likely to get it, how it is assessed, the general categories of treatment that health bodies mention, and what vaccination programmes say about prevention. For the rash itself, see our note on shingles and its rash.

Why shingles can leave nerve pain

Shingles is caused by the varicella-zoster virus, the same virus that causes chickenpox. After chickenpox, the CDC explains, the virus stays dormant in clusters of nerve cells called dorsal root ganglia, and later in life it can reactivate and cause the painful rash (CDC clinical overview of shingles). Because the virus lives in nerves, the nerves themselves can be affected. The CDC lists postherpetic neuralgia, often shortened to PHN, among the complications of shingles.

MedlinePlus, the US National Library of Medicine's health information service, calls PHN the most common complication of shingles. It describes severe pain in the areas where the rash was, and says that many cases improve over weeks or months while some people have pain for many years (MedlinePlus: Shingles). The NHS describes PHN as long-lasting pain that can follow shingles and says it usually gets better gradually (NHS: Post-herpetic neuralgia).

What it feels like

The NHS says the pain usually begins during the shingles rash or soon after, and affects the same area of skin. It can feel like aching, burning or sharp pain. The skin may become very sensitive to touch, pressure or temperature, so that even clothing or a light breeze is uncomfortable. Itching and numbness can also occur. The NHS adds that the pain is often mild, although some people have severe pain.

That last point deserves emphasis. The experience ranges widely, from a nuisance to something that disrupts sleep and daily activity, and the pages we read do not suggest that one pattern is typical for everyone.

How common it is and who is at higher risk

We could not find a reliable, current percentage for how many people with shingles go on to develop PHN on the public pages we opened, so we do not quote one. What the sources do give is a picture of who is more exposed. The CDC says about 1 in 3 people in the United States will develop shingles in their lifetime, and that the risk of shingles and related complications, including hospitalisation, rises sharply after age 50. The CDC links this to declining immunity to the virus with age and with conditions or medicines that suppress the immune system.

The NHS says PHN is more common in older adults and in people with conditions such as diabetes or a weakened immune system. It is also more likely after severe shingles or a rash that covers a large area. MedlinePlus similarly notes that anyone who has had chickenpox can get shingles, that risk goes up with age, and that people with weakened immune systems are at higher risk.

How it is assessed

The public pages say little about a single formal test for PHN. In practice it is recognised from the story: shingles was followed by pain in the same place that persists. The NHS advises seeing a GP, the general practitioner in the UK system, if you have had shingles and pain persists where the rash was. The CDC notes that shingles itself is usually diagnosed from its distinctive rash, though a clinical diagnosis may not be possible without one. A clinician will usually ask about the pain, check the affected area and consider other causes of nerve or skin pain before settling on this explanation.

If you are preparing to describe symptoms to a clinician, our guide to preparing for a dermatology visit has general tips that apply here too. For the wider picture of how skin conditions are worked out, see how dermatologists diagnose skin conditions.

General categories of pain treatment

This is not advice, and treatment decisions belong to your own clinician. What the NHS page lists, in broad terms, is a ladder of options. Simple painkillers are used for mild to moderate pain. Medicines aimed at nerve pain are used if those do not help. Lidocaine plasters, which numb the skin locally, are mentioned for mild pain. A stronger painkiller is mentioned for severe pain, usually for a short time only. The page names the specific medicines, and we leave those to the source rather than repeating them here, since choice and amounts depend on the individual.

MedlinePlus adds that antiviral medicines given early in shingles may make the attack shorter and less severe and may help prevent PHN, and that they work best when started within 3 days after the rash appears. The CDC likewise says treatment is most effective within 72 hours of symptom onset. The NHS states that treating shingles early may reduce the risk of developing PHN.

Where specialists fit

For many people the first point of contact is a family doctor. The NHS says a GP may refer a person with PHN for cognitive behavioural therapy, a talking therapy that helps people manage the effects of long-term pain, or to a neurologist or a specialist pain clinic. Referral is typically considered when pain is severe, interferes with daily activities, or has not responded to medicines from the GP.

In general terms, a neurologist is a doctor who focuses on conditions of the nervous system and can help work out whether nerve damage explains the symptoms. A pain specialist focuses on long-lasting pain and can bring several kinds of treatment together in one plan. Not every health system organises referral the same way, so who you see and how soon varies by country and by insurance or service arrangements.

Vaccination as prevention, and country differences

Public health bodies see vaccination as the main prevention. The CDC recommends 2 doses of the recombinant zoster vaccine (Shingrix) for adults aged 50 and older, and for adults 19 and older who have weakened immune systems because of disease or therapy. MedlinePlus says the vaccine helps prevent shingles and its complications and is given in two doses. The NHS says the shingles vaccine lowers the risk of both shingles and PHN.

Eligibility differs between countries. The NHS page says that in the UK it is offered to people who turned 65 on or after 1 September 2023, people aged 70 to 79, and people aged 50 and over with a severely weakened immune system. The US recommendation starts at 50. Programmes elsewhere may differ again, and they change over time, so a local health authority or clinician is the right place to check current eligibility.

Living with persistent pain

Pain that lasts for months can affect sleep, mood and routines, and it is reasonable to say so to a clinician. Sources describe care as gradual and individual: the NHS notes that PHN usually gets better gradually and that treatments can help. The NHS also lists cognitive behavioural therapy among the referrals a GP may consider, which reflects how long-term pain can reach beyond the skin. What suits one person may not suit another, and it is reasonable to raise the effect on sleep and mood with a clinician.

The short version

Shingles pain that persists after the rash has healed is called postherpetic neuralgia, and public health bodies describe it as the most common complication of shingles. Older age and a weakened immune system raise the risk, treatment tends to be layered, and specialists such as neurologists and pain clinics can be involved when pain is severe. Vaccination is the main prevention, with eligibility that differs by country. Individual care varies, and your own doctor or specialist has the final word.