Station 62
John Harris
Age: 58 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask about the onset, nature, and radiation of the pain, as well as relieving or aggravating factors. It is important to specifically ask about triggers, as in post-herpetic neuralgia the pain may be provoked by light touch or pressure (allodynia).
- Ask about associated symptoms such as the presence of a rash, or any urinary symptoms, particularly haematuria, to help rule out differential diagnoses such as kidney stones.
- Ask about systemic symptoms including fever, nausea, or vomiting, which may indicate pyelonephritis or renal colic.
- Ask about history of recent injuries or trauma
- Ask about constitutional symptoms such as weight loss or night sweats to exclude malignancy.
- Explore the impact of pain on the patient’s daily life.
- Assess the patient’s mood, recognising that chronic pain may be associated with low mood or depression.
- Take a relevant social history including occupation, smoking, and alcohol use.
- Give a diagnosis of post herpetic neuralgia
Example of explanation to patient
John, from what you’ve described, it sounds like you may have a condition called postherpetic neuralgia. This sometimes happens after someone has had shingles. Even though the rash has gone, the nerve in that area can stay irritated or sensitive because of the virus. That’s why you’re still feeling this burning pain in the same area.
It’s not uncommon, and you’re not imagining it, the nerve itself is sending pain signals even though the skin looks healed. The good news is there are treatments that can help calm the nerve and ease the pain. We can go through the options together and find something that works for you.
How does that sound? Would you like me to explain the treatment choices?
Management
Management
- Offer a face-to-face appointment to examine the area and assess for nerve-related tenderness or changes, to support a clinical diagnosis of postherpetic neuralgia.
- Recommend simple self-care measures that may reduce irritation, such as wearing soft cotton or silk fabrics. Advise protecting sensitive skin by applying a barrier, such as a firm bandage, compression clothing, cling film, or a clear plastic dressing (e.g. Opsite®).
- Offer neuropathic pain relief. Options include amitriptyline, duloxetine, gabapentin, or pregabalin. In this case, as sleep is being disrupted, amitriptyline may be a suitable first choice.
- Another alternative is topical lidocaine 5% plasters. Advise that the plaster can be applied once daily over the painful area and kept on for up to 12 hours within a 24-hour period. Discuss the potential for skin irritation but reassure that many patients tolerate it well and find it effective.
- Arrange follow-up in 2 to 4 weeks to review response to treatment and adjust management as needed.
- Provide safety-netting advice, including to seek medical help if symptoms worsen, become more widespread, or significantly affect daily life.
Learning point from this station:
Post-herpetic neuralgia (PHN) is a neuropathic pain syndrome that occurs when pain persists for more than three months following an episode of shingles. It commonly presents with burning or stabbing pain and may also include allodynia (pain from normally non-painful stimuli), hyperalgesia (exaggerated pain response), and occasionally intense itching.
The risk of PHN increases with advancing age, the presence of prodromal pain, severity of the initial shingles rash and pain, and coexisting comorbidities.
In managing postherpetic neuralgia, it is important to tailor treatment to the individual’s preferences to address both the physical symptoms and the wider impact on quality of life.
Topical Capsaicin 0.075% cream (Axsain®) has been used effectively in the past for localised nerve pain. However, clinicians should be aware that this preparation is currently unavailable in the UK, and it is expected to remain unavailable until at least mid-2026.
This highlights the need for clinicians to stay updated with prescribing guidance and medication availability, and to be prepared to offer alternative treatments, such as topical lidocaine plasters, while ensuring the patient is fully informed.