This American Family Physician review, published in August 2026, summarises current practice for herpes zoster and postherpetic neuralgia. About one in three people develop shingles, and 10% to 18% of them go on to postherpetic neuralgia, pain lasting beyond 90 days. Older and immunocompromised people carry the highest risk.
Acute zoster is treated with an antiviral such as aciclovir, valaciclovir or famciclovir, with pain relief. First-line treatments for postherpetic neuralgia are gabapentinoids, serotonin-noradrenaline reuptake inhibitors and tricyclic antidepressants, with topical agents as adjuncts.
The review's central message is prevention. Written for US practice, it recommends two doses of recombinant zoster vaccine for adults aged 50 and over and for immunocompromised adults from 19. Low awareness, dosing errors and missed second doses are the main obstacles. In India the vaccine is not part of the public immunisation programme, so check local availability and cost, and expect the clinician to have to raise it.
- Raise zoster vaccination with every patient aged 50 or over, and with immunocompromised adults.
- Book the second dose when giving the first; missed second doses are a common failure.
- Start an antiviral promptly for acute zoster, particularly in older patients and those with eye involvement.
- Use a gabapentinoid, SNRI or tricyclic first line for postherpetic neuralgia, adjusting for age and kidney function.
- Refer urgently if zoster involves the eye or the tip of the nose.
Why it matters
Postherpetic neuralgia is common, disabling and hard to treat, and most of it is preventable.
Don't overread it
This is a narrative review of existing recommendations, not new trial evidence.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for family medicine, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free