“The shingles rash went months ago — so why does my skin still burn day and night?”

POSTHERPETIC NEURALGIA (PHN) is neuropathic pain persisting in the affected dermatome 90 days or more after the shingles rash began (timed from rash onset; Dworkin 2007, international) — burning, stabbing or electric-shock pain with ALLODYNIA (pain from light touch such as clothing/bedsheets), hyperalgesia and itch — with risk rising with age. Recognise it, reassure that it is a known after-effect rather than a new disease (excluding atypical features), and — crucially — explain why ordinary analgesics fail: paracetamol and NSAIDs target nociceptive/inflammatory pain and are largely ineffective for neuropathic pain, so "nothing works" reflects the wrong tool, not patient failure. Institute the NICE CG173 neuropathic pain ladder (2013, updated 2020): offer a first-line CHOICE of amitriptyline, duloxetine, gabapentin or pregabalin, one at a time, started low and titrated, with realistic expectations (meaningful relief and improved sleep/function built over weeks, rather than zero pain), switching to one of the remaining first-line agents if ineffective or intolerable and tailoring choice to comorbidity and elderly-specific risks (anticholinergic/falls/sedation; gabapentinoid sedation/dependence — Schedule 3 controlled drugs, MHRA Drug Safety Update April 2019, with respiratory depression risk alongside opioids, MHRA October 2017). Add TOPICAL options well-suited to localised pain and allodynia in older people (capsaicin cream per CG173; lidocaine 5% plasters are licensed for PHN but not recommended by CG173, so only as the local formulary allows), address sleep and consider physiotherapy/psychological support and pain-clinic referral if refractory. Avoid long-term opioids (CG173: tramadol only as acute rescue; no other opioids started in non-specialist settings without specialist advice), endless escalation of paracetamol/NSAIDs, and polypharmacy harms. Address the bio-psycho-social toll — sleep, mood, function, isolation — validate it, treat the whole person, and mention shingles VACCINATION for prevention (UKHSA Green Book chapter 28a: Shingrix for adults aged 70 to 79).