Serum Inflammatory Cytokine Levels in Herpes Zoster Patients and Their Association with Postherpetic Neuralgia: A Prospective Study.

BACKGROUND This study aimed to investigate the serum levels of inflammatory cytokines in patients with herpes zoster (HZ) and to assess their correlation with the development of postherpetic neuralgia (PHN). Understanding this relationship may offer insight into the mechanisms of PHN and provide avenues for targeted treatment. MATERIAL AND METHODS We selected 169 patients diagnosed with HZ and 43 healthy controls (HCs) for the study. Serum levels of inflammatory cytokines were measured in all participants. Pain severity was evaluated using the visual analog scale (VAS). Based on follow-up data, the 169 HZ patients were categorized into 2 groups: those who developed PHN (HZ-PHN) and those who did not (HZ-Con). We then analyzed the differences in cytokine levels and their correlation with PHN development. RESULTS Compared to the HCs group, HZ patients exhibited a significant decrease in TNF-a levels and an increase in IL-10 levels (P<0.05, P<0.01). The VAS score was negatively correlated with TNF-alpha levels and positively correlated with IL-10 levels in HZ patients (r=-0.3081, P<0.01; r=0.5619, P<0.01). Distinctive levels of TNF-alpha, IL-6, IL-8, and IL-10 were observed among different pain groups (P<0.05, P<0.01). The HZ-PHN group showed lower TNF-alpha and higher IL-10 levels compared to the HZ-Con group (P<0.05, P<0.01). IL-10 level was identified as an independent risk factor for PHN, with a sensitivity and specificity of 76.4% and 54.3%, respectively. CONCLUSIONS Abnormal levels of inflammatory cytokines are present in HZ patients, and the IL-10 level may serve as a valuable indicator for predicting the risk of developing PHN.

Impact of Type 1 Versus Type 2 Diabetes on Developing Herpes Zoster and Post-herpetic Neuralgia: A Population-based Cohort Study.

Type 2 diabetes is associated with an increased risk of herpes zoster and postherpetic neuralgia. However, the association of type 1 diabetes with herpes zoster or postherpetic neuralgia remains unclear. This retrospective cohort study using Taiwan's Health Insurance Research Database included 199,566 patients with type 1 diabetes and 1,458,331 with type 2 diabetes, identified during the period 2000 to 2012. Patients with type 1 diabetes had a significantly higher risk of developing herpes zoster than those with type 2 diabetes (p < 0.001). Across all age groups, the impact of diabetes on herpes zoster was greater in type 1 than in type 2 diabetes. Patients with both type 1 and type 2 diabetes had a 1.45-fold higher risk of post-herpetic neuralgia than those without diabetes (hazard ratio 1.45, 95% confidence interval 1.28-1.65; hazard ratio 1.45, 95% confidence interval 1.37-1.52, respectively), and there was no difference between the 2 types of diabetes (hazard ratio 1.06; 95% confidence interval 0.93-1.21). The results recommend consideration of herpes zoster vaccination at an earlier age in patients with type 1 diabetes.

A Patient with Herpes Zoster of the Maxillary Division of Trigeminal Nerve Presents for Oral Evaluation and Toothache.

Herpes zoster (HZ) is an acute and painful neurocutaneous infection caused by the reactivation of a latent varicella-zoster virus in the dorsal root or cranial nerve ganglia. It is characterized by 3 stages: prodromal, acute, and chronic. During the prodromal stage, reactivation in the maxillary branch of the trigeminal nerve closely mimics odontalgia, and HZ should be in the differential diagnosis. Patients with HZ develop painful lesions following the affected dermatome. Laboratory testing confirms the diagnosis; treatment is with antiviral agents. Early detection and treatment shorten the course of the infection and lessen the severity of the associated postherpetic neuralgia.

Persistent 'postherpetic neuralgia' and well-demarcated plaque.

Extended treatment for a previous condition provided a key to the diagnosis.

Diagnosis and treatment of varicella-zoster virus infection with herpetic visceral neuralgia without rash: A case report.

RATIONALE: Herpes zoster (HZ) is an infection caused by the varicella-zoster virus reactivation, often leading to peripheral nervous system infection and pain. This case report aimed to present 2 patients with damaged sensory nerves originating from the visceral neurons of the lateral horn of the spinal cord. PATIENT CONCERNS: Two patients presented intractable, severe lower back pain and abdominal pain, but without rash or herpes. A female patient was admitted 2 months after symptom onset. She was presented with paroxysmal, acupuncture-like pain in the right upper quadrant and around the umbilicus without apparent incentives. A male patient was presented with recurrent episodes of paroxysmal and spastic colic in the left waist and left middle abdomen for 3 days. Abdominal examination showed no tumors or organic lesions in their intra-abdominal tissues or organs. DIAGNOSES: After excluding organic lesions on the waist and in abdominal organs, patients were diagnosed with herpetic visceral neuralgia without rash. INTERVENTION: The treatment for herpes zoster neuralgia or postherpetic neuralgia was applied for 3 to 4 weeks. OUTCOME: Antibacterial and anti-inflammatory analgesics were not effective in either patient. The therapeutic effects of herpes zoster neuralgia or postherpetic neuralgia treatment were satisfactory. LESSONS: Herpetic visceral neuralgia can be easily misdiagnosed due to the absence of a rash or herpes, resulting in delayed treatment. When patients have severe, intractable pain but no rash or herpes, and the biochemical and imaging examinations are normal, the treatment method for HZ neuralgia can be used. If the treatment is effective, HZ neuralgia is diagnosed. If not, shingles neuralgia can be ruled out. Further investigations are required to elucidate the mechanisms of pathophysiological changes in varicella-zoster virus-induced peripheral HZ neuralgia or visceral neuralgia without herpes.

Efficacy of indwelling trocar therapy for postherpetic neuralgia: A retrospective study of an acupuncture method.

Postherpetic neuralgia (PHN) is a common complication of herpes zoster. As a kind of continuous acupuncture, indwelling trocar therapy (ITT) involves inserting a trocar into the skin and retaining the soft cannula in the body for 24 h. However, the efficacy and safety of ITT on PHN require further verification. In this study, the medical records of 122 patients with PHN were retrospectively analyzed. Patients were divided into the control group (patients who received conventional drug therapy) and the ITT group (patients who underwent ITT combined with conventional drug therapy). The Visual Analog Scale (VAS), Quality of Sleep (QS), 36-Item Short Form Health Survey (SF-36), dosage of drug and adverse events were analyzed at days 1, 3, 7, 14, 28, 90, and 180 after treatment. The total efficiency rate (TER) was analyzed after 6 months of follow-up. The VAS, QS and SF-36 scores in the ITT group improved substantially compared with those in the control group after 6 months of follow-up (p < 0.001). The average dosage of anticonvulsants and analgesics decreased significantly in the ITT group (p < 0.001). The TER in the control group was 52.46%, compared with 73.77% in the ITT group (p < 0.05). There were no adverse events, such as bleeding and infection, observed in the ITT group. For PHN patients, the combination of ITT and medicine therapy reduced VAS, improved quality of life, increased the efficiency rate, remarkably reduced the dosage of traditional medicine, and had no significant side effects. In addition, ITT was more effective in patients with a short duration of PHN than in chronic PHN patients.

Correlation Between Electromyography and Severity and Prognosis of Upper Limb Herpes Zoster.

BACKGROUND: There are differences in the clinical treatment schemes for patients with different severities of herpes zoster (HZ). Therefore, effective and accurate evaluation of disease severity is of great significance for the formulation of treatment plans. Postherpetic neuralgia (PHN) with long-term chronic pain leads to anxiety, depression, and even suicidal thoughts, which place a heavy burden on society and the family. Therefore, identifying risk factors and taking early intervention to reduce the occurrence of PHN is meaningful. Electromyography (EMG) can provide technical support for the early diagnosis of peripheral neuropathy. However, the application of EMG in HZ and PHN has rarely been reported. The purpose of this study was to compare the detection indices of EMG in patients with different severities and prognoses of HZ and to analyze the application of EMG in severity and prognosis of HZ. OBJECTIVE: This study aimed to explore the relationship between EMG and severity and prognosis of upper limb HZ. STUDY DESIGN: A retrospective, observational study. SETTING: The study was carried out in the Pain Department of the affiliated Hospital of Jiaxing College in Jiaxing, China. METHODS: A total of 91 patients with upper limb HZ at the First Hospital of Jiaxing between January 2015 and August 2021 were enrolled. The patients were divided into mild, moderate, and severe HZ groups according to their numeric rating scale (NRS) scores. The occurrence of PHN was defined as a poor prognosis. The patients were divided into non-PHN and PHN groups according to the occurrence of PHN. Motor and sensory conduction indices of the median nerve were measured in each group. Spearman's correlation analysis was used to analyze the relationship between the EMG-related data of the median nerve and the NRS score and muscle strength. Univariate and multivariate logistic regression analyses were used to determine the independent influencing factors of PHN in patients with upper limb HZ, and the receiver operating characteristic (ROC) curve was drawn to evaluate the predictive value of EMG-related data in patients with upper limb HZ. RESULTS: Among 91 patients, there were 29 patients in the mild HZ group, 31 in the moderate HZ group, and 31 in the severe HZ group. The sensory nerve action potential (SNAP) amplitude of the median nerve in the severe and moderate HZ groups was lower than that in the mild HZ group, and that in the severe HZ group was lower than that in the moderate HZ group (F = 22.192, P < 0.05). Through Spearman's correlation analysis, it was found that the compound muscle action potential (CMAP) and SNAP amplitudes of the median nerve on the affected limb were negatively correlated with the NRS score (r = -0.266, P = 0.011; r = -0.778, P < 0.001), and there was no significant correlation between each index and muscle strength (P > 0.05). Among 91 patients, 44 and 47 were in the non-PHN and PHN groups, respectively. Univariate and multivariate logistic regression analyses showed that the CMAP amplitude of the median nerve on the affected limb (OR = 0.241, 95% CI: 0.098-0.567, P = 0.001) and SNAP amplitude (OR = 0.268, 95% CI: 0.110-0.628, P = 0.002) were independent influencing factors of PHN. Through the analysis of the ROC curve, it was found that the CMAP and SNAP amplitudes of the median nerve on the affected limb had a high predictive value for PHN (AUC = 0.657, P = 0.010; AUC = 0.773, P < 0.001). The cutoff values were 5.45 mV and 10.80 mV, respectively; and the predictive value of the 2 indices combined was the highest (AUC = 0.785, P < 0.001). LIMITATIONS: The nonrandomized, single-center, small sample size, and retrospective design are major limitations of this study. CONCLUSION: The CMAP and SNAP amplitudes of the median nerve on the affected limb were related to the degree of pain in patients with upper limb HZ. The CMAP and SNAP amplitudes of the median nerve on the affected limb can be used as prognostic factors for patients with upper limb HZ, and CMAP amplitude combined with SNAP amplitude is more valuable in predicting prognosis.

[Herpes zoster-prevention, diagnosis, and treatment]. / Herpes zoster ­ Prävention, Diagnostik und Behandlung.

BACKGROUND: Herpes zoster (HZ) is a common skin disease resulting from a regionally limited reactivation of a latent infection with the varicella zoster virus (VZV). Despite its usually self-limiting course, HZ is associated with a considerable individual and public health burden of disease, particularly due to its high rate of postherpetic neuralgia (PHN). OBJECTIVES: To improve knowledge of the current recommendations for the prevention, diagnosis and treatment. MATERIALS AND METHODS: Narrative review and summary of current guideline recommendations. RESULTS: In Germany, the recombinant VZV subunit zoster vaccine is recommended for all adults of 60+ years and for immunocompromised persons of 50+ years. The diagnosis of HZ is clinical; in case of uncertainty, laboratory investigations can help confirm the diagnosis. For patients with HZ ophthalmicus, HZ oticus or neurological complications, an interdisciplinary approach is advantageous. Antiviral treatment should be started as early as possible; various factors, including the duration and location of the disease, the patient's age and signs of a complicated course, serve to determine the indication to initiate an antiviral medication. The choice of the appropriate treatment depends, among other factors, on the intravenous availability, comorbidities and intake preferences. Early and sufficient analgesic treatment according to the WHO pain ladder and, if required, with anticonvulsant adjuvants is necessary to treat acute pain and to reduce the risk for PHN. CONCLUSION: Implementation of the current recommendations for the prevention, diagnosis and treatment of HZ and PHN is important to reduce the high burden of disease and improve quality of life of the patients.

Pain changes and new neurologic sign in post-herpetic neuralgia: a clue in the diagnosis of malignancy-a case report.

Herpes zoster (HZ) results from the reactivation of latent varicella-zoster virus in the dorsal root ganglion neurons. The most common complication of HZ is post-herpetic neuralgia (PHN), characterized by persisting neuropathic pain in the affected dermatome after the rash recedes. The immune system is more compromised in older people, which leads to an increase in the incidence of HZ and PHN. Several studies have revealed that HZ or PHN is associated with an increased risk of malignancy in immune-suppressed patients. An 83-year-old man visited our pain clinic with facial pain 6 months after he was diagnosed with recurred HZ on the right V1 dermatome. He was diagnosed with HZ on the right C2 dermatome 5 years ago. He could not perform a right lateral gaze for the past 3 months. Moreover, the symptoms did not improve and the pain was aggravated on the face and head. We considered two possibilities: HZ affecting motor neuron and occult malignancy. Brain magnetic resonance imaging and magnetic resonance angiography showed a mass lesion that should have been differentiated, and his blood was positive for prostate specific antigen. The probability of occult malignancy should be taken into account in elderly patients with HZ or PHN.

Presentation, Management, and Prevention of Herpes Zoster.

The purpose of the Research to Practice column is to review and critique current research articles that directly affect the advanced practice nurse's (APN's) practice in the emergency department. This review examines the findings of Schmidt and Rowbotham's (2017) article, "Aggressive Noninvasive Treatment of Acute Herpes Zoster for the Prevention of Postherpetic Neuralgia. Herpes Zoster: Postherpetic Neuralgia and Other Complications." The authors completed an extensive literature review and created 6 key clinical recommendations for treating acute herpes zoster to prevent postherpetic neuralgia, including prevention, patient education and counseling, proper diagnosing, medication selection, and treatment specific to acute herpes zoster postherpetic neuralgia. This review provides a strategy to allow APNs to confidently recognize and treat acute herpes zoster and postherpetic neuralgia to reduce patient risks and avoid mistreatment of acute herpes zoster and postherpetic pain.

Zoster Eye Disease Study: Rationale and Design.

PURPOSE: The purpose of this study was to describe the rationale and design of the Zoster Eye Disease Study (ZEDS). METHODS: ZEDS is a National Eye Institute-supported randomized clinical trial designed to determine whether 1 year of suppressive valacyclovir in patients with herpes zoster ophthalmicus (HZO) reduces complications because there is currently no high-quality evidence to support its use. Eligible patients are 18 years and older, immunocompetent, have a history of a typical rash at disease onset, and have had a record of active epithelial or stromal keratitis or iritis within 1 year before enrollment. Exclusion criteria include estimated glomerular filtration rate less than 45 or pregnancy. The primary endpoint is the time to first occurrence of new or worsening dendriform epithelial keratitis, stromal keratitis without or with ulceration, endothelial keratitis, or iritis due to HZO during 12 months of study treatment requiring prespecified treatment changes. The study has 80% power to detect a 30% difference between treatment groups, with a 30% rate of endpoints by 1 year assumed among controls. Secondary and exploratory questions include whether there is a persistent treatment benefit during the 6 months after treatment, whether development of postherpetic neuralgia varies by treatment group, and whether vaccinations against herpes zoster affect study outcomes and coronavirus disease 19 status. RESULTS: Over approximately 4 years, over 400 study participants have been enrolled. CONCLUSIONS: ZEDS aims to provide scientific evidence on whether suppressive valacyclovir treatment improves outcomes in HZO and should become the standard of care.

Efficacy of gabapentinoids for acute herpes zoster in preventing postherpetic neuralgia: a systematic review of randomized controlled trials.

Gabapentinoids (e.g., gabapentin and pregabalin) have been established as a treatment for postherpetic neuralgia (PHN), but their effects on the prevention of PHN are unclear. This systematic review aimed to evaluate the efficacy of gabapentinoids for acute herpes zoster (HZ) in preventing PHN. PubMed, EMBASE, CENTRAL, and Web of Science were queried December 2020 to collect data on relevant randomized controlled trials (RCTs). A total of four RCTs (including 265 subjects) were retrieved. Overall, the incidence of PHN was lower, but not statistically significant in the gabapentinoid-treated group compared to the control group. Subjects treated with gabapentinoids were more likely to experience adverse events such as dizziness, somnolence, and gastrointestinal symptoms. This systematic review of RCTs showed that the addition of gabapentinoids during acute HZ are not significantly effective in preventing PHN. Nevertheless, the evidence on this subject remains limited. Physicians should carefully weigh the risks and benefits of prescribing gabapentinoids during the acute phase of HZ owing to its side effects.

Effect of pain neuroscience education and transcutaneous electrical nerve stimulation on trigeminal postherpetic neuralgia. A case report.

INTRODUCTION: Postherpetic neuralgia (PHN) is a complex neuropathic painful condition in which pain is a direct consequence of the response to peripheral nerve damage experienced during herpes zoster attack. PHN is the most common chronic complication of herpes zoster and it causes considerable suffering, affecting the physical functioning and psychological well-being of patients. OBJECTIVE: To describe the effect of a conservative treatment using pain neuroscience education (PNE) and transcutaneous electrical nerve stimulation (TENS) in a patient with trigeminal PHN. CASE DESCRIPTION: A 67-year-old woman sought care for pain, dysfunction, and sensory loss in the left jaw. The assessment included: 1) pain, using the numerical pain rating scale (NPRS), pressure pain threshold (PPT), Douleur Neuropathique 4 (DN4), McGill Pain Questionnaire (MPQ), Graded Chronic Pain Scale (GCPS), and classic body charts of the cranial region; 2) somatosensory function, by means of mechanical detection threshold (MDT) and pressure pain threshold (PPT); 3) jaw function, using the Jaw Functional Limitation Scale-20 (JFLS-20); and 4) psychosocial features, by means of the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorders Questionnaire-7 (GAD-7). Treatment consisted of 12 sessions of PNE and TENS. OUTCOMES: After treatment, a clinically significant improvement in NPRS, DN4, MDT, GCPS, and PHQ-9 was observed. CONCLUSION: In this case report, a treatment based on the combination of PNE and TENS seemed to have contributed to improving pain, sensory abnormalities, and jaw function. Psychosocial factors also showed a trend to improve after the treatment.

Computed Tomography-Guided Radiofrequency Ablation of the Cervical Dorsal Root Ganglia in 27 Patients with Cervical and Occipital Postherpetic Neuralgia.

BACKGROUND Postherpetic neuralgia (PHN) is a common complication of herpes zoster virus infection that is associated with intense pain. The present study aimed to investigate the use of computed tomography (CT)-guided radiofrequency ablation (RFA) of the cervical dorsal root ganglia (DRG) for treatment of cervical and occipital PHN in 27 patients at a single center. MATERIAL AND METHODS Twenty-seven patients with PHN in the cervical and/or occipital region were enrolled. After imaging the area of PHN in the patients, axial scanning was performed on the upper cervical segment in the spinal scanning mode. The puncture path was defined and then RFA therapy (90°C for 180 s) was performed by targeting the corresponding intervertebral foramen. Patients were followed 2 days later and at 1, 3, 6, and 12 months after surgery. Observation at each follow-up visit included rating of pain on a visual analog scale (VAS) and assessment of complications and adverse events. RESULTS VAS scores significantly decreased in patients with PHN after RFA compared with their scores before RFA (P<0.05). Skin sensation decreased in the area that was originally painful and allodynia significantly diminished. CONCLUSIONS The findings from this small study from a single center showed that CT-guided percutaneous RFA of cervical DRG safely and effectively reduced cervical and occipital PHN in the short term.

A novel method to simultaneously record spinal cord electrophysiology and electroencephalography signals.

The brain and the spinal cord together make up the central nervous system (CNS). The functions of the human brain have been the focus of neuroscience research for a long time. However, the spinal cord is largely ignored, and the functional interaction of these two parts of the CNS is only partly understood. This study developed a novel method to simultaneously record spinal cord electrophysiology (SCE) and electroencephalography (EEG) signals and validated its performance using a classical resting-state study design with two experimental conditions: eyes-closed (EC) and eyes-open (EO). We recruited nine postherpetic neuralgia patients implanted with a spinal cord stimulator, which was modified to record SCE signals simultaneously with EEG signals. For both EEG and SCE, similar differences were found in delta- and alpha-band oscillations between the EC and EO conditions, and the spectral power of these frequency bands was able to predict EC/EO behaviors. Moreover, causal connectivity analysis suggested a top-down regulation in delta-band oscillations from the brain to the spinal cord. Altogether, this study demonstrates the validity of simultaneous SCE-EEG recording and shows that the novel method is a valuable tool to investigate the brain-spinal interaction. With this method, we can better unite knowledge about the brain and the spinal cord for a deeper understanding of the functions of the whole CNS.

Serum interleukin-10 level increases in patients with severe signs or symptoms of herpes zoster and predicts the duration of neuralgia.

Herpes zoster (HZ) is caused by reactivation of latent varicella zoster virus (VZV) in the cranial nerve or dorsal root ganglia, with spread of the virus along the sensory nerve to the dermatome. Postherpetic neuralgia is a feared complication of HZ and impairs patients' quality of life enormously. However, there is no predictor of the duration of neuralgia. Our objective was to investigate whether there are correlations between the duration of neuralgia and serum levels of potential biomarkers in order to find practical predictors of the duration of neuralgia. Patients who were diagnosed with HZ at our hospital from April 2013 to January 2014 were included in this study. Serum levels of cytokines and other biomarkers were measured using commercial enzyme-linked immunosorbent assay kits. Thirty patients (15 men and 15 women) with HZ were enrolled in this study. The mean age was 66.1 ± 9.2 (standard deviation) years (range, 51-84 years). Four patients were evaluated as having mild, 19 as having moderate, and seven as having severe HZ. Patients with severe HZ suffered from neuralgia for a significantly longer period of time than patients with mild-to-moderate HZ (9.86 ± 8.25 months vs. 2.01 ± 2.68 months, severe vs. mild-to-moderate, p = 0.0021). The serum interleukin (IL)-10 level was significantly higher in patients with severe HZ than in those with mild-to-moderate HZ (12.93 ± 3.27 pg/mL vs. 6.74 ± 3.72 pg/mL; severe vs. mild-to-moderate; p = 0.0487). Furthermore, the serum IL-10 level was significantly correlated with the duration of neuralgia (r = 0.5193, p = 0.0111). Lastly, the serum IL-10 level significantly decreased after treatment in comparison with that before treatment (from 8.15 ± 4.46 pg/mL to 4.32 ± 11.83 pg/mL, p < 0.0001). In conclusion, these results suggest that the serum IL-10 level is an objective biomarker of the severity of HZ, and that the serum IL-10 level can be a practical predictor of the duration of neuralgia.

Thermographic follow-up of postherpetic neuralgia (PHN) subsequent to Ramsay Hunt syndrome with multicranial nerve (V, VII, VIII and IX) involvement: a case report.

BACKGROUND: Ramsay Hunt syndrome (RHS) is caused by a reactivation of varicella-zoster virus (VZV) infection, and it is characterized by the symptoms of facial paralysis, otalgia, auricular rash, and/or an oral lesion. Elderly patients or immunocompromised patients, deep pain at the initial visit and no prompt treatment are significant predictors of postherpetic neuralgia (PHN). When PHN occurs, especially involved cranial polyneuropathy, multiple modalities should be administered for patients with the intractable PHN. The use of thermography in the follow-up of PHN secondary to RHS with multicranial nerve involvement has not yet been described yet in the literature. CASE PRESENTATION: The patient was a 78-year-old man with the chief complaint of a 3-month history of PHN secondary to RHS with polycranial nerve (V, VII, VIII, and IX) involvement. Multimodality therapy with oral gabapentin, pulsed radiofrequency (PRF) application to the Gasserian ganglion for pain in the trigeminal nerve region, linear-polarized near-infrared light irradiation for pain in the facial nerve region, and 2% lidocaine spray for pain in the glossopharyngeal nerve region was used to the treat patient, and follow-up evaluations included thermography. This comprehensive treatment obviously improved the quality of life, resulting in considerable pain relief, as indicated by a decrease in the numerical rating scale (NRS) score from 9 to 3 and a decrease in thermal imaging temperature from higher to average temperature on the ipsilateral side compared with the contralateral side. Lidocaine spray on the tonsillar branches of the glossopharyngeal nerve resulted in an improvement in odynophagia, and the NRS score decreased from 9 to 0 for glossopharyngeal neuralgia after three applications. CONCLUSION: Although the use of thermography in the follow-up of RHS with multiple cranial nerve (V, VII, VIII, and IX) involvement is very rare, in this patient, thermal imaging showed the efficacy of combination therapy (oral gabapentin, 2% lidocaine sprayed, PRF application and linear-polarized near-infrared light irradiation) and that is a good option for treatment.