The Burning, Searing Pain of Postherpetic Neuralgia

Clinical Presentation: Burning, Searing Pain

A 71-year-old man reports severe "burning and searing" pain over his thoracic region. He last saw the nurse practitioner (NP) 2 months ago, when he had a case of acute herpes zoster (shingles), which was treated with acyclovir and naproxen for pain.

History and Physical Examination

History. The NP obtains the following information about the patient's pain:

His "burning and searing" pain radiates across his anterior lower right thoracic region. The NP asks the patient to use his finger to outline the painful area on his chest, which measures 10 cm x 20 cm (4 in x 8 in).
The site of this pain is the same site of the herpes zoster episode that the patient experienced 2 months ago. The skin is pink where the herpes zoster lesions have healed.
Aside from his current pain, his recovery from the herpes zoster episode was uneventful.
The pain is continuous in nature, lasting all day and most of the night. He has difficulty going to sleep, and the pain often awakens him from sleep.
Clothing worn over his thoracic region increases his pain. He has stopped wearing T-shirts and is wearing only a light cotton dress shirt today.
The patient rates his average daily pain intensity as 6 and his worst pain as 8 on the 0-to-10 numerical rating scale.
The patient was previously socially and physically active. He attended an exercise class and ate lunch 3 times weekly with friends at the local gym. The pain has made it difficult to exercise, and wearing exercise clothing aggravates his pain. He now prefers to stay home, where he can wear light clothing and watch television.
Although naproxen 550 mg taken every 12 hours relieved the pain associated with acute herpes zoster infection, the same drug and dose reduces his current persistent pain only slightly or not at all. The effect seems to last only about 1 hour. He does not like to take medication and has been taking the naproxen irregularly.
On the recommendation of a friend, he tried applying cold packs to the painful region of his skin. However, the initial application of cold was uncomfortable, and he abandoned this strategy.
His goal is pain relief, allowing him to return to his usual exercise and social activities.

Physical examination. Physical examination revealed the following:

General appearance: healthy older man
Height 6', weight 160 lb
Oral temperature: 97.8°F
Heart rate: 80 beats/min
Respiratory assessment: bilateral breath sounds are equal and clear; respiratory rate, 20 breaths/min; patient is a nonsmoker
Skin is warm; nail beds and general skin color are pink
Blood pressure: 110/68 mm Hg
Neurologic assessment: sensation of pain increases significantly when the skin of his lower right anterior thoracic region is stroked lightly with a cotton ball