Management of Postherpetic Neuralgia in Elderly Women

First-Line Topical Treatment

The American Geriatrics Society recommends the use of a 5% lidocaine patch as the ideal choice for elderly patients, offering excellent efficacy (NNT = 2) with minimal systemic absorption, making it particularly suitable for older adults or those with comorbidities 1, 2
High-concentration capsaicin (8% patch) is another non-sedating topical option that can provide pain relief for at least 12 weeks 2
To minimize capsaicin side effects (erythema and pain), apply 4% lidocaine for 60 minutes before capsaicin application 2

The American College of Physicians recommends gabapentin as a first-line oral pharmacological treatment for postherpetic neuralgia, with a number needed to treat (NNT) of 2.64 2, 3
Gabapentin should be started with 100-200 mg/day in elderly patients, with gradual titration to 1800-3600 mg/day in divided doses, as doses above 1800 mg/day do not offer additional benefit 1, 2, 3
The American Geriatrics Society suggests that nortriptyline is preferable to amitriptyline, with excellent efficacy (NNT = 2.64) and better tolerability, offering equivalent analgesic benefits 2

Opioids, such as oxycodone, morphine, and methadone, show efficacy (NNT = 2.67) but should not be used as first-line agents due to risks of pronociception, cognitive impairment, respiratory depression, and potential for abuse 2
Tramadol shows efficacy with an NNT of 4.76 2
Combination therapy (e.g., morphine with gabapentin) may be more effective when single agents provide inadequate relief, allowing for lower doses of each medication while providing additive effects 2

Cognitive-behavioral therapy (CBT), hypnosis, and physical and occupational therapy may be beneficial 2

The American College of Physicians advises against using lamotrigine for postherpetic neuralgia due to lack of convincing evidence of efficacy and risk of lamotrigine-associated skin rash 2
Always adjust the dose based on renal function in elderly patients to prevent toxicity 3
Monitor closely for neurological side effects (somnolence, dizziness, confusion) that are particularly problematic in older adults 1