I recently saw a 72-year-old woman with long-standing T2DM who developed shingles, followed by severe post-herpetic neuralgia.
She had persistent burning pain and marked allodynia, with major sleep disruption and loss of function. Glycemic control was reasonable, and renal function was acceptable for her age.
We went through the standard early steps with limited benefit. She was later referred for interventional management and underwent nerve blocks, which helped only briefly.
This is the part of care I find hardest.. not because there is nothing left to try, but because the path forward becomes much less clear.
In cases like this (PHN, diabetic neuropathy, chemo-related neuropathy), additional options sometimes come up, including OTCs or supplements. Not as “answers,” but because patients are still suffering and the evidence base is thin.
What I struggle with is not finding papers. It’s how to think about them:
- When is it reasonable to extend data from one neuropathic condition to another?
- Which processes are likely driving symptoms here- peripheral nerve injury, central sensitization, metabolic factors, inflammation?
- How do you judge whether something is worth trying versus unlikely to help?
- How do you avoid offering false hope while still acknowledging the patient’s distress?
Alpha-lipoic acid is one example that has decent data in diabetic neuropathy and sometimes comes up in discussions of other neuropathic pain states.
I’m not looking for treatment recommendations. I’m genuinely interested in how others think through these situations when formal guidance doesn’t offer much direction.
Do you have a personal framework you rely on? Or do you generally avoid going beyond guideline-supported options?
Nuclear grade8% capsaicin patches applied under medical supervision for 60 minutes will destroy the C fiber nociceptors responsible for most of the pain underlying PHN. Need to pretreat the area with lidocaine cream first (the capsaicin feels like a regular sunburn on normal skin but is often intolerable for areas affected by PHN). Main downside is that it needs to be repeated every 3 months or so. Should be covered by insurance, but since the only FDA approved 8% capsaicin patch on the market is still under patent and costs $$$, expect to jump through some prior auth BS first.Interesting. I have a never thing - Brachial Radial Pruritus- and I use capsaicin liberally. And it works. But it’s 0.025%. Could you imagine how potent that is. That 1/40th % burns already. I imagine 8% (320x stronger ) would feel pretty strong.
I once slapped a 1x1 inch square on my arm to see what it’s like. Nothing much for the first 20 minutes then it felt like I had a strong sunburn in that area for a few hours. I could see how that could be agonizing for someone with PHN-induced allodynia, especially for a larger treated area.
The brand on the market right now is Qutenza. Our main indications for it are PHN and painful diabetic peripheral neuropathy. But, we'll try it for other neuropathic pains if we're desperate enough.
What commercial insurances have you had success with? I've had it universally rejected.
Need to remember this and look into application. I've never heard of this before. Good tip
I have seen Botox (high density subcutaneous) and spinal cord stimulation be effective for resistant PHN. It's a tough condition.
I think Botox is worth a try for such situations, but getting insurance to cover it is challenging but not impossible (but you basically have to write a essay of an appeal letter citing the available evidence). Though at this point people are often so desperate they will pay the few grand it costs out of pocket. You might be able to get one of the botulinum toxin pharmas to give you a sample.
To answer your questions.
It would depend on the extension of the process. Small fiber vs large vs mixed.
I wouldn't hesitate to get emg if unsure of what's driving things as well as general inflammatory markers. I think this is part of the art of medicine.
Having the open dialogue of limited data but some findings for similar issues in different processes. Can even let patient know this and have that talk that it's multimodal approach.
Qutenza (high dose topical capsaicin) can also be useful here but it’s applied in office and requires some care with handling.
What dermatome(s)?
T4-T5, right
Can send for nerve ablations. Most common is RF. I do them via non-invasive stereotactic radiosurgery.
Thoracic are even safer to do, because even if you get the motor root a bit, it doesn’t cause problems.
Most of the time interventional will have done a block, waited a couple weeks, then done RFA. Of course this typically provides maybe 6 months of relief. I think rad-onc referrals for this are under-utilized as SRS is likely to be longer lasting relief and doesn't add much risk. However, if RFA isn't helping there is a stronger argument to trial spinal cord stimulator or pump.
Unfortunately, there are only two of us in the country right now doing SRS dorsal root rhizotomies…. But I’ve been engaged by the manufacturer to start a course this year!
Agree with this, especially if nerve block was beneficial.
As far as supplements I think it's just the typical fish oil, vitamin e, choline, ala, b12, etc. they've been mostly studied in rats.
Not strong evidence but some evidence for nerve issues. I have chronic nerve issues from CIDP and seems to lessen the tingling for me. Now placebo is 30% and N=1. I usually allow patients to use supplements that won't harm them if they find benefit with the conversation of a lot not having strong background.
Your local functional neurosurgeon or pain specialist will offer some sort of dorsal root stimulator or peripheral field stimulator. These can help dramatically.
I agreed with ICN block + RFA. You can go even further with a temporary PNS which is a clear indication here or even permanent PNS. SCS implant is another option. The worst case scenario is IT pump. Please send her to a pain interventionalist. There are more than just medication alone.
Pain management here Rec trying qutenza capsaicin patches, topical ketamine, intercostal block and RFA, and refractory cases SCS trial/implant
What % ketamine do you use? Just in glaxal base or something similar?
I frame it around mechanism first, then reversibility, then risk. If the biology plausibly overlaps and downside is low, a time-limited trial with clear stop rules feels reasonable. I am explicit that evidence is thin and goals are symptom relief, not cure. Validating suffering without overpromising matters as much as the intervention.
I think if you’ve exhausted western medicine approaches, look for non-harmful alternatives. In this case, medical acupuncture with percutaneous electrical stimulation can be helpful. Possibly medical marijuana at bedtime or topical CBD oil, although at that age, might be safer for topical.
Agree 100%. A lot of chronic neuropathic pain patients try accupuncture and/or medical cannabis and end up stopping gabapentin, duloxetine, the usual agents I've tried. It's happened enough that I don't really care for 'trial' evidence and we all underestimate the placebo response in these patients alone is 30-40%, up to 50% for some conditions- most of the trials in chronic pain are low quality anyways. Accupuncture is better tolerated by some of my patients than gabapentin especially when aggressively dose titrated. Is it as effective for every patient? Obviously not, but it is something to try and certain patients will swear by it. These work often enough that they are standard suggestions of mine for third line management of neuropathic pain. These patients want options and want to see that you give a crap and are still trying to help them, which means go outside the box.
Really appreciate the thoughtful discussion here. I’ve asked to schedule a follow-up with the patient to review the full range of options raised. Given her preferences, we’ll likely start by fully exploring non-invasive approaches such as capsaicin and acupuncture.
Have you already ruled out contributing etiologies that shingles could have unmasked (e.g., underlying B12 deficiency if she takes metformin)? Better to test first before throwing supplements at it in hopes of a placebo effect.
Pain dose ketamine