Treatment of Postherpetic Neuralgia With

Low Level Laser Therapy

Laser therapy helps reduce PHN pain and offers clinicians an effective adjunct to
conventional therapies.
By Randolph V. Merrick, MD, FAAFP, ABFM, Fred Kahn, MD, FRCS(C) and Fernanda
Saraga, PhD
Page 1 of 2
The emerging trends in genomics, regenerative, and anti-aging medicine combined with new
research in alternative/complementary approaches, and bioenergetics in general, have fueled
continued interest in the various forms of available therapeutic electromagnetic interventions,
including low level laser therapy (LLLT). This article examines an important relationship
between LLLT application and its beneficial effects on a very painful condition, that of
postherpetic neuralgia (PHN). More investigations focusing on conservative disease-specific
interventions should be encouraged and funded, since they offer a preferred alternative to
pharmaceutical and/or surgical management. The authors should be commended for
providing a protocol-specific LLLT algorithm that has shown promise in assisting the
recovery of patients suffering from PHN. As well, continued research involving cold laser
applications needs to be supported so the full range of therapeutic benefits can be validated
and subsequently applied in clinical medicine.
Tiziano Marovino, DPT, MPH, DAIPM

Herpes zoster, also known as shingles, produces a painful vesicular rash that results from the
reactivation of the varicella zoster virus (VZV), the virus that originally causes chickenpox.
Although the rash typically resolves over the course of 4 to 5 weeks, the pain may persist for
months, or even years, after the rash has disappeared. Known as PHN, this phenomenon can
often be debilitating to the patient. A number of different treatment options are available to
clinicians, including pharmaceuticals, nerve block injections, and physiotherapy, but
unfortunately no single therapy is 100% effective at reducing PHN.1,2 LLLT is a noninvasive,
pain-free, light-based therapy that uses red and infrared light to resolve the inflammatory
process and eliminate pain in patients with PHN. We present a number of PHN cases that
have responded favorably to LLLT and review the mechanisms of action of the technology.
Background

The VZV is a linear, double-stranded DNA virus that causes two pathological manifestations.
Initial infection with the virus, usually during childhood, may result in chickenpox. The virus
then migrates to a dorsal root ganglion, where it can remain latent indefinitely (Figure 1).
Later in life, immune system depression or stress can trigger a reactivation of the herpes
zoster virus. The lifetime risk of developing herpes zoster is approximately 30%.3,4 An
estimated 1 million new cases of herpes zoster occur each year in the United States,5 resulting
in 50,000 to 60,000 hospitalizations. On occasion, the disease can lead to loss of bladder or
bowel control and may even be fatal.

The incidence and severity of herpes zoster has been shown to increase with advancing age.5
Individuals over the age of 60 years make up approximately 40% to 50% of the 1 million new
cases that occur each year. The increased risk of herpes zoster with advancing age is thought
to be caused in part by immunosenescence, the gradual deterioration of the immune system
that is part of the natural aging process. In addition, patients who are immunocompromised
have a greater chance of manifesting the disease, with increased severity of symptoms.6
Herpes zoster is characterized by a unilateral vesicular eruption in a dermatomal distribution,
most commonly over the trunk and cranial regions. Initial symptoms prior to the appearance
of a rash include headache, pain, malaise, and acute photophobia. The rash itself may be
accompanied by pruritus, altered sensitivity to touch, or allodynia. Initially, the
maculopapular rash is characterized by varying degrees of inflammation, and it progresses to
take the form of coalescing clusters of clear vesicles containing high concentrations of VZV.4

PHN is a common complication of herpes zoster that affects 50% of individuals over the age
of 50 years who develop shingles. PHN is characterized by ongoing pain subsequent to the
resolution of the rash associated with this disease. The pain has been described as an
unrelenting sharp, burning, stabbing symptom that interferes with sleep, work, and other
activities of daily life. It can lead to social withdrawal and depression.2 The duration of PHN
can last from 30 days to long after the disappearance of the dermatological lesions. In some
cases, the pain persists for many years.7

As shown in Figure 1, PHN results in inflammation of the sensory root ganglia, the dermis of
the associated dermatome, and frequently, the posterior and anterior horns of the grey matter,
meninges, and both dorsal and ventral nerve roots.

LLLT Treatment

For more than 40 years, LLLT has been effectively used in the treatment of wounds and in
acute and chronic musculoskeletal conditions, including degenerative disc disease, repetitive
stress injuries, muscle strains, and arthritis.8 LLLT has been cleared by the FDA for the relief
of minor muscle and joint pain, arthritis, muscle spasm, relieving stiffness, and promoting
relaxation of muscle tissue. Certain devices have also been approved for treating carpal
tunnel syndrome and rotator cuff injuries specifically. The therapy is traditionally not covered
by insurance and patients may pay between $30 and $60 per half hour of treatment,
depending on the healthcare practitioner.

LLLT is a noninvasive, pain-free, light-based therapy that uses a combination of red and
infrared light in the form of laser and superluminous light-emitting diodes. The power output
of these devices is below the level of surgical or other high-intensity lasers. Photon particles
of light are absorbed by the mitochondria through cytochrome c oxidase and result in
increased cellular adenosine triphosphate levels.8

In the case of neuropathic pain, LLLT has been proposed to mediate analgesia by releasing
local neurotransmitters such as serotonin,9 promoting the release of endorphins,10 while
simultaneously decreasing prostaglandin E2 and bradykinin levels. An increase in anti-
inflammatory cytokines, interleukin (IL)-10, along with a decrease in pro-inflammatory
cytokines, tumor necrosis factor-a, and IL-1b, allows for the rapid resolution of the
inflammatory process.11 LLLT has been well documented to stimulate tissue regeneration
including angiogenesis, collagen production, muscle and nerve regeneration, cartilage
production, and even bone formation.8 The inflammation that causes the abnormal
stimulation of the nerves in the case of PHN is reduced rapidly with LLLT.

In a double-blind crossover trial of LLLT for PHN, all patients who received treatment
demonstrated a reduction in pain severity of between 40% and 95% (mean value, 74%) and a
reduction in pain distribution (as measured by body surface perimetry using a universal
goniometer) of 49% to 84% (mean value, 64%).12 Patients all began with a pain level of 10
out of 10, as measured on the visual analogue scale (VAS)—with 0 representing no pain, 2 -
mild pain, 4 - moderate pain, 6 - severe pain, 8 - very severe pain, and 10 - intolerable pain.
Therefore, a reduction of 40% to 95% on VAS represents a significant impact on the quality
of life of these patients.

Follow-up of patients between 3 to 6 months after therapy revealed that 80% of the patients
had maintained their improvement in pain levels and pain distribution. The large age range of
the patients (55 to 82 years) and duration of PHN (6 months to 8 years) could account for the
relatively wide range of pain reduction demonstrated in this study. In particular, 50% of the
patients were over the age of 70 years, and 25% had suffered from the condition for more
than 4 years. A detailed analysis of age and severity of condition compared to treatment
response was not presented in the article. Despite this variability, all patients saw an
improvement of at least 40%, which is comparable to the most successful pharmacological
treatment, but without the harmful side effects (Table 1).

Application of LLLT in PHN

Prior to treatment, pain is measured on VAS. In general, patients presenting with PHN
usually categorize their pain at a 9 out of 10, which has a large impact on their quality of life
and daily activities. Patients experiencing such a severe level of pain will find a reduction in
the VAS scale of 2 to 3 points to be significant, as compared to a patient who begins with a
moderate pain level of 4 or 5 out of 10. Patients undergoing LLLT normally notice an
immediate improvement in pain of approximately 20% to 30% during the administration of
the first 3 treatments. During the course of 10 to 15 treatments, patients usually experience
80% to 90% relief of pain and other symptoms.

LLLT treatment consists of the application of red and infrared superluminous diode arrays
and laser probes both to the rash directly and to the spinal nerve root that supplies the sensory
nerves to the associated regional dermatome. We used the BioFlex Laser Therapy System
(Meditech International Inc., Toronto, Canada), with direct contact over the lesion sites and
over the nerve roots involved—at their origin and along the course of the nerve. The
following 3-step approach was used for each site:

1. 660 nm (red), GaAlAs, superluminous diode (SLD) array, pulsed (50 Hz, 50% duty cycle) 10
mW/cm2, 75 cm2, 6 minutes
2. 840 nm (infrared), GaAlAs, SLD array, pulsed (10 Hz, 60% duty cycle), 20 mW/cm2, 75 cm2, 6
minutes
3. 830 nm (infrared), GaAlAs, laser diode, 0.1 cm2, continuous wave, 540 mW/cm2, 6 minutes

Treatments can take 18 to 42 minutes depending on the extent of the lesions and affected
dermatomes. The treatment program consists of 3 times per week for the first 3 weeks and
then is reduced to 2 times per week until the patient is asymptomatic. As noted, treatments
are usually not covered by insurance, and patients have to pay out of pocket.

Treatment is noninvasive, has no adverse effects, and no drug interactions. It can be safely
administered over metal implants and pacemakers without concern. The use of non-steroidal
anti-inflammatory drugs is discouraged as they can mask symptoms and interfere with the
effects of treatment, which works to expedite and resolve the inflammatory process, rather
than suppress it. The following clinical profiles illustrate the effectiveness of LLLT in the
hands of the authors.

Clinical Profiles

Case 1

The patient is a 79-year-old retired veteran who presented with a 10-day-old VZV rash with a
left C-5 distribution. Valacyclovir (Valtrex) was prescribed 3 days after onset of shingles.
The patient’s pain level was at 9 out of 10 on the VAS despite being prescribed pregabalin
(Lyrica, 75 mg every 12 hours) and oxycodone (OxyContin, 15 mg every 4 hours).

Laser therapy treatment was administered directly over the rash and over the spinal ganglia of
the fifth cervical spine nerve. No other form of therapy was administered. The patient
received 18 LLLT treatments over the course of 2 months. After 10 treatments, the patient’s
pain level was reduced to 5 out of 10 on VAS and he was able to reduce his oxycodone
usage. As his rash disappeared, the remaining 8 treatments focused on the spinal ganglia until
he became completely asymptomatic and all medications were discontinued. The patient
remained asymptomatic on follow-up 1 year later.

Case 2

The patient is a 68-year-old musician who presented with a 1-year history of PHN following
a severe attack of shingles in the right T6-T7 region. He was prescribed gabapentin (900 mg
3 times per day), but no antivirals. His pain level was at 9 out of 10 when he presented at the
clinic and he had not performed musically in more than 1 year.

Laser therapy treatment was administered over the spinal ganglia of the T5-T8 region. No
other form of therapy or medication was administered. The patient received 23 LLLT
treatments over the course of 2 months. After 10 treatments, his pain level was reduced to 3
out of 10 and he discontinued the use of gabapentin. He continued to receive 13 additional
treatments, at which point he was asymptomatic and was able to return to performing music
in a normal fashion. The patient remained asymptomatic at 1-year follow-up.

Case 3

The patient is a 51-year-old woman complaining of pain and dermatological manifestations

over her right lower back, thigh, and inguinal regions. These were acutely inflamed and
demonstrated extensive vesiculopapular- and plaque-type lesions of extensive distribution
(Figure 2). Ten days prior to her initial presentation, the patient awoke with severe right
lower back pain radiating to the inguinal and thigh areas. The dermatological lesions
developed over the subsequent 3 days. The pain was excruciating in degree and required 10
Tylenol tablets per every 24-hour period. These provided only minimal relief. No antivirals
had been prescribed.

The patient initially had 3 laser therapy treatments within the first week, which resulted in a
significant reduction in pain and marked diminution of the dermal lesions. No other form of
therapy or medication was administered. The patient received 15 treatments over the course
of 1 month and was asymptomatic at the conclusion of this course of treatment. The patient
remained asymptomatic at 1-year follow-up.

Summary

While PHN has been the subject of more randomized controlled trials than any other type of
neuropathic pain syndrome except diabetic neuropathy,7 no pharmacological treatment to
date has shown a maximum efficacy of greater than 40%. In addition, the adverse side effects
further exacerbated with advanced age demonstrate that pharmacological treatment does not
resolve PHN. Laser therapy has been shown to be effective in reducing pain by 40% to 95%
in patients and offers clinicians a more effective solution without adverse effects or the
complications of conventional therapies.