The Journal of Pain, Vol 15, No 2 (February), 2014: pp 149-156

Available online at www.jpain.org and www.sciencedirect.com

Use of S-LANSS, a Tool for Screening Neuropathic Pain, for

Predicting Postherpetic Neuralgia in Patients After Acute Herpes
Zoster Events: A Single-Center, 12-Month, Prospective Cohort
Study
Soo Ick Cho,* Cheol Heon Lee,* Gyeong-Hun Park,y Chun Wook Park,*
and Hye One Kim*
*Department of Dermatology, Kangnam Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea.
y
Department of Dermatology, Dongtan Sacred Heart Hospital, College of Medicine, Hallym University, Hwaseong,
Korea.

Abstract: Postherpetic neuralgia (PHN) is one of the most severe sequelae of herpes zoster events.
Several risk factors have been reported for PHN, including old age, severe skin rash, and intense pain.
This study therefore aims to evaluate the usefulness of the Self-completed Leeds Assessment of
Neuropathic Symptoms and Signs pain scale (S-LANSS) in conjunction with previously reported risk
factors for predicting PHN. A group of herpes zoster patients (N = 305) were included in the cohort
study. Subjects were asked for their demographic information, clinical symptoms and signs, intensity
of pain by visual analog scale (VAS), and S-LANSS. They were followed up in clinical visits or via tele-
phone for 12 months. Nineteen patients (6.2%) suffered from PHN in this study. Using logistic regres-
sion, 3 risk factors for PHN were identified: age $70 years, high VAS scores, and high S-LANSS scores.
Prediction of PHN using VAS ($8) and S-LANSS ($15) criteria achieved a sensitivity of 78.9% and spec-
ificity of 78.0%. Prediction of PHN in elderly patients ($70 years), using the criteria of VAS ($6) and
S-LANSS ($15) as well, achieved 100% sensitivity and 57.1% specificity. S-LANSS could be a useful
prediction tool for PHN, particularly if combined with previously well-known risk factors and VAS.
Perspective: Among acute herpes zoster patients, subjects with characteristics of neuropathic pain
showed high frequency of PHN. The tools for screening neuropathic pain like S-LANSS could be help-
ful for predicting PHN and enabling early intervention of pain management.
2014 by the American Pain Society
Key words: Herpes zoster, neuropathic pain, postherpetic neuralgia, screening tool, S-LANSS.

H
erpes zoster (HZ) is characterized by a unilateral,
dermatomal, and painful vesicular rash that re-
sults from the reactivation of latent varicella zos-
ter virus (VZV) in dorsal root or cranial sensory ganglia.
Its incidence increases with advancing age, as does its
most harassing complication, postherpetic neuralgia
Received July 1, 2013; Revised October 10, 2013; Accepted October 17,
2013.
This research was supported by Basic Science Research Program through
the National Research Foundation of Korea (NRF) funded by the Ministry
of Education (No. 2011-0013003 and No. 2012R1A1B3002196) and by Hal-
lym University Research Fund 2013 (HURF-2013-33).
The authors declare no conflicts of interest.
Address reprint requests to Hye One Kim, MD, Department of Derma-
tology, Kangnam Sacred Heart Hospital, College of Medicine, Hallym Uni-
versity, 1 Singil-ro, Yeongdeungpo-gu, Seoul, 150-950, Korea. E-mail:
hyeonekim@gmail.com
1526-5900/$36.00
2014 by the American Pain Society
http://dx.doi.org/10.1016/j.jpain.2013.10.006
(PHN).11 PHN is often resistant to analgesic medications
and impacts on quality of life.5,12,18 The definition of
PHN differs from study to study regarding its time
threshold and painfulness. Now it is commonly defined
as pain $3 on a 10-point scale, which persists 90 or
more days after rash onset.5,23
The mechanism of pain caused by HZ is complicated and
has not been fully elucidated. The current hypothesis as-
sumes that there is a combination of nociceptive (tissue
damage and inflammation) and neuropathic (damage
of peripheral nerve) pain in the acute phase, then a pro-
gression from peripheral to central nervous system
changes, resulting in PHN.7 Among these changes, neuro-
pathic pain, rather than nociceptive pain, is supposed to
be more closely related to the progression to PHN.13 In
previous studies, old age, severe pain at presentation,
and severe skin rash have been verified as independent
predictive factors for development of PHN.26

149
150 The Journal of Pain
Recent studies of HZ focused on prevention, including
vaccination,23 and early, active interventions in the acute
phase of HZ for preventing PHN.17,18 To determine high-
risk groups for PHN among HZ patients, several studies
have been used to predict the development of PHN.
They included established factors (eg, older age, inten-
sity of pain, and severity of skin rash), as well as novel fac-
tors (eg, psychological predictors or smoking).13,14,24
The characteristics and intensity of pain are subjec-
tive; thus, there have been many trials to evaluate the
qualities of pain for distinguishing neuropathic-
dominant from nociceptive pain.2 The Self-completed
Leeds Assessment of Neuropathic Symptoms and Signs
pain scale (S-LANSS) is one of them. It consists of 7 items
for assessing neuropathic symptoms and signs. Higher
scores on the S-LANSS suggest pain of predominantly
neuropathic origin. S-LANSS is easy to score as a self-
report tool and has been tested and validated in several
clinical settings.2
To our knowledge, there is no study that has used
screening tools to identify neuropathic pain for predict-
ing the development of PHN. Herein, we applied S-LANSS
to predict the development of PHN in HZ patients and
found that S-LANSS may be useful for advanced identifi-
cation of patients at high risk for developing PHN.
Methods
Participants
We enrolled adult patients ($18 years) diagnosed with
HZ at the Department of Dermatology, Kangnam Sacred
Heart Hospital, Hallym University, Seoul, Korea, between
May 2010 and April 2012. When a patient suspected of
having HZ visited the outpatient clinic, 2 dermatologists
(S.I.C. and H.O.K.) teamed up to determine whether it
was HZ. If both of the clinicians agreed with the diag-
nosis of HZ, then the patient was enrolled in the study.
If there was a difference in diagnosis, it was confirmed
by polymerase chain reaction for VZV DNA (nested poly-
merase chain reaction) from a blister fluid. Eligible par-
ticipants were patients 1) with a physician-confirmed
diagnosis of HZ, 2) recruited within 14 days of rash onset,
and 3) who were capable of completing study question-
naires. Exclusion criteria were as follows: 1) could not
describe their pain-related symptoms appropriately, 2)
previous history of HZ (recurrence), and 3) received any
treatment of HZ at other clinics. None of the participants
had been previously vaccinated against HZ.
This study protocol was approved by the institutional
review board of Kangnam Sacred Heart Hospital. Signed,
informed consent was obtained from all participants.
Methods
Physician Assessment
Just after enrollment, the patients were asked for their
demographics; their history of HZ including the onset of
pain and skin lesion; dermatome affected; underlying
systemic diseases including malignancies, diabetes melli-
tus (DM), and hypertension; and whether they were
S-LANSS for Predicting Postherpetic Neuralgia
currently receiving or had recently received medication.
In addition, the severity of the HZ event was evaluated
by severity of skin lesion. The severity of skin rash was
assessed as 1 of 3 grades (mild: <25 lesions, including pap-
ules, vesicles, or crusted vesicles; moderate: 2550 lesions;
severe: >50 lesions).13
Assessment of Severity and Nature of
Initial Pain
The severity of initial pain was estimated using a 10-
point visual analog scale (VAS) from 0 (no pain) to 10 (worst
pain you can imagine). To evaluate whether the pain was
neuropathic or nociceptive, the S-LANSS was used with
permission of the author.3 The S-LANSS was translated
into Korean and validated by authors and experts in En-
glish. The S-LANSS consists of 7 items, termed dysesthesia,
autonomic, evoked, paroxysmal, thermal, allodynia, and
tender/numb (Table 1). The participants filled out a ques-
tionnaire asking whether they had felt the symptoms of
any of the 7 items over the last week. Each item was as-
signed a score from 1 to 5, and the total score could range
Table 1. Questions of the S-LANSS3
TOTAL SCORE: 24 POINTS
1. In the area where you have pain, do you also have pins and nee-
dles, tingling or prickling sensations?
a) NoI dont get these sensations (0)
b) YesI get these sensations often (5)
2. Does the painful area change colour (perhaps looks mottled or
more red) when the pain is particularly bad?
a) NoThe pain does not affect the colour of my skin (0)
b) YesI have noticed that the pain does make my skin look
different from normal (5)
3. Does your pain make the affected skin abnormally sensitive to
touch? Getting unpleasant sensations or pain when lightly stroking
the skin might describe this.
a) NoThe pain does not make my skin in that area abnormally
sensitive to touch (0)
b) YesMy skin in that area is particularly sensitive to touch (3)
4. Does your pain come on suddenly and in bursts for no apparent
reason when you are completely still? Words like electric shocks,
jumping and bursting might describe this.
a) NoMy pain doesnt really feel like this (0)
b) YesI get these sensations often (2)
5. In the area where you have pain, does your skin feel unusually hot
like a burning pain?
a) NoI dont have burning pain (0)
b) YesI get burning pain often (1)
6. Gently rub the painful area with your index finger and then rub a
non-painful area (for example, an area of skin further away or on
the opposite side from the painful area). How does this rubbing feel
in the painful area?
a) The painful area feels no different from the non-painful area (0)
b) I feel discomfort, like pins and needles, tingling or burning in the
painful area that is different from the non-painful area (5)
7. Gently press on the painful area with your finger tip then gently
press in the same way onto a non-painful area (the same non-
painful area that you chose in the last question). How does this feel
in the painful area?
a) The painful area does not feel different from the non-painful
area (0)
b) I feel numbness or tenderness in the painful area that is different
from the non-painful area (3)
Cho et al
from 0 to 24. The higher scores suggest that the pain is pre-
dominantly neuropathic, not nociceptive.
Follow-Up of the Patients and the
Identification of PHN
During hospitalization or outpatient visits, the patients
were asked to estimate the intensity of their pain in the
last week using the 10-point VAS. When the patients
stopped visiting the clinic, they were called or e-mailed
to ask about the intensity and cessation of their pain 1,
3, 6, and 12 months after the onset of rash. During these
follow-ups, if the patients showed any type of painful dis-
ease other than HZ involving the previously HZ derma-
tome, the patients were excluded from analysis. HZ
patients who had clinically insignificant pain (VAS rating
<3) initially and during the follow-up periods were also
excluded from analysis. PHN was defined as HZ-
associated pain that was rated 3 or higher on the 10-
point VAS more than 90 days after the onset of rash.
Statistical Analysis
All statistical analyses were conducted using SPSS 12.0
for Windows (SPSS Inc, Chicago, IL). The results obtained
from the HZ patients with PHN and without PHN were
compared using the Mann-Whitney test, the Pearsons
chi-square test, Fishers exact test, or the Mantel-
Haenszel chi-square test. Logistic regression was conduct-
ed to find predictive factors for PHN. Factors having a
significant association with PHN at month 3 were entered
into a logistic regression as exploratory variables. The
odds ratio for significant factors was calculated with
95% confidence intervals. The predictive factors and their
combinations were compared using receiver operating
characteristic (ROC) curve analysis with area under the
curve (AUC) to measure their diagnostic accuracy.
Kaplan-Meier analysis was performed for comparison of
the days to the cessation of significant pain. Significance
levels for all analyses were set at P < .05.
Results
Patient Population
A total of 375 patients initially enrolled for the study,
and 70 were dropped because of follow-up loss (n = 29),
having clinically insignificant pain (VAS <3) initially or dur-
ing the follow-up periods (n = 37), or showing other types
of painful diseases during the follow-up periods (n = 4).
Thus, 305 HZ patients (111 males and 194 females)
finished this study. The mean 6 standard deviation of
ages of the patients was 52.82 6 14.30 years, and the
ages ranged from 18 to 83 years. The patients were consid-
ered in 4 age groups: <49 years, n = 109 (35.7%); 50
59 years, n = 99 (32.5%); 6069 years, n = 62 (20.3%);
and >70 years, n = 35 (11.5%).
Clinical Features and the Severity of
Initial Skin Lesion
On average, the pain started 5.97 6 3.57 days before
the first hospital visit, whereas the skin rash started
The Journal of Pain 151
4.22 6 3.06 days before. One hundred seventy-two pa-
tients (56.4%) had prodromal symptoms such as pain or
paresthesia before appearance of the skin rash. The
most commonly affected dermatome was thoracic
(n = 162, 53.1%), followed by trigeminal (n = 55,
18.0%), cervical (n = 46, 15.1%), lumbar (n = 24, 7.9%),
and sacral (n = 18, 5.9%). One hundred sixty-nine pa-
tients (55.4%) had systemic underlying disease, including
hypertension (n = 83, 27.2%), DM (n = 37, 12.1%), cardio-
vascular disease (n = 30, 9.8%), and any other malig-
nancies (n = 24, 7.9%).
The HZ patients whose skin lesions were categorized as
mild, moderate, or severe were 73 (24.0%), 203 (66.5%),
and 29 (9.5%), respectively.
General Pain and Neuropathic Symptoms
and Signs
The mean 6 standard deviation of initial pain in-
tensity using the VAS was 6.67 6 2.04. The
mean 6 standard deviation of S-LANSS scores was
14.02 6 6.41. The most common positive item was dyses-
thesia (n = 236, 77.4%), followed by allodynia (n = 205,
67.2%), evoked (n = 189, 62.0%), tender/numb (n = 176,
57.7%), paroxysmal (n = 167, 54.8%), thermal (n = 136,
44.6%), and autonomic (n = 100, 32.8%).
Treatment of Acute HZ
Seventy-eight patients (25.6%) were admitted to the
hospital, whereas the others were followed up at the
outpatient clinic. All patients received antiviral therapy
such as acyclovir (10 mg/kg intravenously every 8 hours
for 5 days), famciclovir (250 mg orally every 8 hours for
7 days), or valacyclovir (1 g orally every 8 hours for 7
days), and 152 of them (49.8%) started the medication
within 3 days after onset of rash. Most patients took
other medications for relieving symptoms such as
nonsteroidal anti-inflammatory drugs (morniflumate
700 mg/day; n = 299, 98.0%), tramadol (100 mg/day;
n = 287, 94.1%), systemic steroid (methylprednisolone 8
mg/day; n = 245, 80.3%), amitriptyline (10 mg/day;
n = 200, 65.6%), or pregabalin (150 mg/day)/gabapentin
(300 mg/day; n = 145, 47.5%). Some patients were
treated with nerve blocks in the pain clinic (n = 6,
2.0%) within 1 month after the initial visit.
Follow-Up of the Patients and the
Identification of PHN
Nineteen (6.2%) patients were diagnosed as having
PHN. Their mean pain intensity (VAS) at 90 days after
the onset of rash was 4.26 6 1.66. The frequency of
PHN increased with age. Though only 1.8% for those
less than 49 years old, the PHN frequency rose to 5.1%
for those aged 50 to 59 years, 8.1% for those aged 60
to 69 years, and 20% for those older than 70 years.
PHN patients had higher mean age, more severe skin le-
sions, higher VAS and S-LANSS scores, and more frequent
underlying DM than those without it. Other factors were
not significantly different between patients with and
without PHN (Tables 2 and 3). PHN patients had
152 The Journal of Pain S-LANSS for Predicting Postherpetic Neuralgia
Table 2. Characteristics of Herpes Zoster Patients With and Without PHN
DEMOGRAPHIC AND CLINICAL CHARACTERISTICS WITHOUT PHN (N = 286) WITH PHN (N = 19) P VALUE
Age 52.07 6 14.00 64.11 6 14.48 <.001*
Gender (M/F) 37.4/62.6 21.1/78.9 .218
Trigeminal nerve involvement 17.1 31.6 .113
Prodromal pain 55.6 68.4 .275
Duration of skin rash (days)y 4.23 6 3.10 4.00 6 2.47 .751
Skin rash severity (mild/moderate/severe)z 24.5/67.1/8.4 15.8/57.9/26.3 .045*
Any underlying diseases 54.9 63.2 .483
DM 10.8 31.6 .007*

NOTE. Values are mean 6 standard deviation or percentages.

*P < .05.
yDays before clinical visit.
zSkin rash severity: mild = <25 lesions, including papules, vesicles, or crusted vesicles; moderate = 2550 lesions; severe = >50 lesions.

undergone more intensive initial treatments (eg, hospi-
tal admission, pregabalin/gabapentin, or nerve block)
than non-PHN patients (Table 4). The treatments did
not show significant difference after adjustment based
on the VAS score, according to the Mantel-Haenszel
chi-square test. The number of patients with pain that
persisted for 180 days after the onset of rash was 11
(3.6%), and for 360 days later, 10 (3.3%).
Predictive Model for PHN
Among the predictive factors mentioned above, we
chose some for analysis by logistic regression. First, age, in-
tensity of pain, and severity of skin rash were chosen as pre-
viously well-known risk factors. In addition, the S-LANSS
score was included. DM was excluded as it overlapped
with age. Three significant predictive factors were indi-
cated by the logistic regression analysis: age $70 years,
high VAS score, and high S-LANSS score (Table 5).
Then the sensitivity and specificity for predicting PHN
from VAS and S-LANSS scores was calculated using the
ROC curve. The AUC for VAS was .783 and for S-LANSS
was .741. The AUC for both VAS and S-LANSS by regres-
sion analysis was .838, which was higher than either
VAS or S-LANSS alone. The value was highest when VAS
scores, S-LANSS scores, and age were included (AUC =
.868) (Fig 1). The cut-off value (which shows highest
values of sensitivity 1 specificity) for the VAS was 7.5
(sensitivity = 78.9%, specificity = 62.9%, positive predic-
tive value [PPV] = 12.4%, negative predictive value
[NPV] = 97.8%). For the S-LANSS, the cut-off was 14.5
(sensitivity = 100%, specificity = 50.3%, PPV = 11.8%,
NPV = 100%). The final cut-off point of 15 or more was
superior to the original cut-off point of 12 or more (sensi-
tivity = 100%, specificity = 37.8%, PPV = 9.6%, NPV =
100%). If we predict that the HZ patient with initial
VAS $8 and S-LANSS $15 was in the high-risk group
for PHN retrospectively, the sensitivity was 78.9%, the
specificity was 78.0%, PPV was 19.2%, and NPV was
98.2%, which were better than when using either VAS
or S-LANSS alone (Fig 2). In addition, Kaplan-Meier anal-
ysis showed that the high-risk group (initial VAS $8 and
S-LANSS $15) endured a longer period to cessation of
clinically significant pain (VAS $3) than did the low-risk
group (initial VAS <8 or S-LANSS <15: Log rank test; chi-
square = 23.98, P < .001; Fig 3).
For those in the high-risk group whose age was
>70 years, the cut-off value of 7.5 for VAS was inferior
to 5.5 (sensitivity = 71.4% vs 100%, specificity = 21.4%
vs 14.3%, PPV = 18.5% vs 22.6%, NPV = 75% vs 100%).
The cut-off value of 14.5 for the S-LANSS was still
adequate (sensitivity = 100%, specificity = 53.6%, PPV =
35%, NPV = 100%). If we predict the PHN as described
above (VAS $6 and S-LANSS $15), the sensitivity was
100%, specificity was 57.1%, PPV was 36.8%, and NPV
was 100% (Fig 4).

Table 3. Pain in Herpes Zoster Patients With and Without PHN

PAIN INTENSITY AND PAIN CHARACTERISTICS WITHOUT PHN (N = 286) WITH PHN (N = 19) P VALUE
Duration of pain (days)y 5.98 6 3.63 5.84 6 2.63 .875
Mean initial pain intensity (10-point VAS) 6.54 6 2.01 8.58 6 1.50 <.001*
Mean Initial S-LANSS 13.68 6 6.43 19.05 6 3.36 <.001*
Dysesthesia 75.9 100 .010*
Autonomic 31.8 47.4 .162
Evoked 61.5 68.4 .550
Paroxysmal 53.1 78.9 .033*
Thermal 45.1 36.8 .483
Allodynia 65.0 100 .001*
Tender/numb 55.6 89.5 .003*

NOTE. Values are mean 6 standard deviation or percentages.

*P < .05.
yDays before clinical visit.
Cho et al The Journal of Pain 153
Table 4.Course of Treatment for Herpes Zoster
Patients With and Without PHN
WITHOUT PHN, PHN, % P
% (N = 286) (N = 19) VALUE
Admission 23.1% 63.2% <.001*
Antiviral therapy (3 days)y 49.8 47.4 .836
Nonsteroidal anti- 97.9 100 1.000
inflammatory drug
Tramadol 93.7 100 .614
Amitriptyline 64.7 78.9 .318
Pregabalin/gabapentin 44.8 89.5 <.001*
Systemic steroid 79.7 89.5 .386
Nerve block at clinic 1.0 15.8 .004*

*P < .05.
yTreated within 3 days after onset of rash.

Discussion
PHN is referred to as persisting or relapsing pain after
healing of an acute HZ rash. The definition of PHN has
been disputed for a long time, especially regarding its
time threshold, but recently it was defined as pain $3
on a 10-point scale that persists 90 or more days after
onset of the rash.5,23 The incidence of PHN is assumed
to be 9 to 34%, increasing as a patient gets older. A
large clinical study showed that its incidence was
12.4% in patients older than 60 years, whereas for
those $70 years, it was 18.5%.9,23
In previous studies, older age, severe pain at presenta-
tion, and severe skin rash have been verified as indepen-
dent predictive factors for PHN.26 In addition, prodromal
symptoms and duration, HZ localization, psychosocial
factors, female sex, and use of proper antiviral therapy
have made results suspicious and inconsistent in some
studies.26 Incidences of both HZ and PHN have steadily
increased as the population ages.28
Once an initial HZ event progresses to PHN, quality of
life is critically affected and the condition does not usu-
ally adequately respond to treatment.5,8,26 Recent
interest in PHN researches focuses on not only on
treatment but also on prevention (ie, by zoster
vaccine or gabapentin).17,18,23 In several studies,
attempts were made to predict PHN with the goal of
preventing it. Most of them featured use of the
Table 5.Logistic Regression Analysis for
Prediction of PHN
COMPONENT ODDS RATIO
Age (<49, reference)
Age 5059 2.689 (.48215.000)
Age 6069 2.829 (.46417.259)
Age $70 6.729 (1.19337.946)
Mean initial pain intensity 1.583 (1.1032.272)
(10-point VAS)
S-LANSS (per score)y 1.156 (1.0361.289)
Skin rash severity, mild (reference)
Skin rash severity, moderate .934 (.2243.894)
Skin rash severity, severe 1.928 (.34810.688)
*P < .05.
y24 points per score.
Figure 1. Predictive factors for PHN and combination
compared by ROC curve analysis. The area under the ROC curve
was .783 for VAS (intensity of pain) and .741 for S-LANSS (quality
of pain). The area under a ROC curve for both VAS and S-LANSS
by regression analysis was .838, which was higher than for VAS
or S-LANSS alone. The value was highest when VAS, S-LANSS,
and age were included (area under ROC curve = .868).
established predictive factors including age, pain
intensity, and skin rash severity.13,16,21,22,25,27 Other
studies added some original factors, such as deep
pain,14 psychosocial factors,15,22 smoking/trauma
history,24 or performing usual activities.6 In addition,
Meister et al19 proposed a scoring system for calcu-
lating the risk of PHN based on female sex, age, skin
rash, localization, and prodromal symptoms. Even so,
there is currently no established and widely accepted
predictive model for PHN.
The etiology of PHN remains unclear and inconclu-
sive. A persuasive hypothetical model proposes that
viral replication causes damage of peripheral nerves
or tissue damage and inflammation, which contrib-
utes to acute neuropathic or nociceptive pain in
each case, and that the prolonged pain induces
PHN by chronic functional and structural changes.7,26
Interestingly, Jung et al13 reported that patients
with subacute herpetic neuralgia (HZ pain that
persists >1 month but <3 months after onset of skin
P VALUE lesion) had more severe and widespread rash than
.164 did those without persistent pain. These suggest that
.259 of the 2 components of acute HZ painnociceptive
.260 and neuropathicthe latter plays a more significant
.031* part in the pathophysiology of PHN.
.013* As pain is a subjective symptom, the evaluation is
mainly dependent on description by the patients.
.009* Several screening tools have been developed to iden-
.537 tify neuropathic pain.2 One of them, the LANSS pain
.926
scale, is a useful tool for distinguishing patients with
.453
neuropathic dominant pain from those with nocicep-
tive dominant pain.1 The S-LANSS is a modified version
of LANSS, which can be filled out by patients
154 The Journal of Pain
Figure 2. Results of PHN prediction factors for patients experiencing acute HZ events. Patients with initial VAS $ 8 (sensitivity 78.9%,
specificity 62.9%, PPV 12.4%, NPV 97.8%); patients with initial S-LANSS $15 (sensitivity 100%, specificity 50.3%, PPV 11.8%, NPV
100%); high risk patients with initial VAS $ 8 and S-LANSS $ 15 (sensitivity 78.9%, specificity 78.0%, PPV 19.2%, NPV 98.2%). Predic-
tion based on VAS and S-LANSS gave better results than on either used alone.
themselves without the need for assistance or
pinprick testing, and is more suitable for large-scale
research.3 It consists of 7 items, each of which was as-
signed a score from 1 to 5, and each assessment a total
score from 0 to 24. A cut-off point of 10 or 12 was pro-
posed earlier.3
Abnormal sensory function such as allodynia and
changed sensory thresholds have been reported in PHN
patients.4,20 In addition, patients with allodynia and
pinprick hypesthesia during acute HZ events tend to
develop PHN.10 These items are included in the S-LANSS
Figure 3. Result of the analysis of differences in interval to
cessation of clinically significant pain. The high-risk group
(initial VAS $8 and S-LANSS $15) experienced a longer period
to cessation of clinically significant pain (VAS $3) than lower
risk groups (initial VAS <8 or S-LANSS <15) (Log rank test; chi-
square = 23.98, P < .001).
S-LANSS for Predicting Postherpetic Neuralgia
score. In the present study, the initial S-LANSS score was
higher for HZ patients with PHN than for those without
PHN. The predictive model in this study (VAS 1 S-LANSS)
showed higher power than did VAS only
(sensitivity 1 specificity = 156.9% vs 141.7%). Even in
high-risk groups of those older than 70 years, the
VAS 1 S-LANSS model was still more meaningful than
VAS alone (sensitivity 1 specificity = 157.1% vs
114.3%). These results assumed that considering the
quality as well as the intensity of the pain would
augment the prediction of PHN and help to choose the
high-risk group for PHN, and that this would allow the
start of proactive, intensive treatment.
The present study had some limitations. First, some
items in the S-LANSS score (eg, evoked or thermal pain)
did not correlate with the occurrence of PHN. The LANSS
model includes several neuropathic diseases other than
PHN, so further study is required to establish a zoster-
specific screening tool. Second, the treatment modal-
ities were not controlled, and the number of PHN
patients was not large enough for definitive answers.
In conclusion, this study was the first to show that ex-
isting screening tools to identify neuropathic pain
could help predict PHN in patients with acute HZ
events. To predict PHN, physicians should consider not
only the age, intensity of pain, and severity of the
skin rash but also the quality of the pain when they
meet HZ patients. The prediction of PHN might support
the application of active and intensive intervention in
groups at high risk for PHN. Further studies and
consensus are required to establish guidelines and a
predictive model for preventing PHN among the
increasing number of HZ patients.
Acknowledgments
The authors express their deepest thanks to Dr. Ben-
nett for permitting the use of the S-LANSS scores, and
for his encouragement.
Cho et al
Figure 4. Results of PHN prediction factors for patients older than 70 years. Elderly patients with initial VAS (pain severity) $6 (sensi-
tivity 100%, specificity 14.3%, PPV 22.6%, NPV 100%); elderly patients with initial S-LANSS $15 (sensitivity 100%, specificity 53.6%,
PPV 35%, and NPV 100%); highest risk elderly patients with initial VAS $6 and S-LANSS $15 (sensitivity 100%, specificity 57.1%, PPV
36.8%, and NPV 100%).
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