Herpes zoster and postherpetic neuralgia

Herpes zoster, or shingles, is the reactivation of the chickenpox virus in a nerve, which causes a painful rash along one band of skin. Pain that persists after the rash heals is postherpetic neuralgia (PHN), a form of neuropathic pain, meaning pain caused by damage to the nerve itself. The acupuncture trials split along that line: some treat the acute rash and its pain, often alongside antiviral drugs, and also count how many people go on to develop PHN; others treat established PHN. Most compare acupuncture, electroacupuncture, fire needling or bloodletting and cupping with drugs, and one large trial compares electroacupuncture with a sham.

No Cochrane review of acupuncture for zoster

A search of the Cochrane Database of Systematic Reviews in October 2026 found reviews of antivirals, corticosteroids and vaccines for zoster and PHN, and none of acupuncture for either. The nearest is a 2017 Cochrane review of acupuncture for neuropathic pain by Ju and colleagues, searched to February 2017, which admitted only trials lasting eight weeks or longer. It included six trials with 462 adults with chronic peripheral neuropathic pain, all of manual acupuncture and all at high risk of bias for blinding. One trial, of 45 people, compared acupuncture with sham and found no clear difference in pain intensity. GRADE, the scale that rates confidence in a result from high to very low, put the overall evidence at very low. The authors found the data insufficient to support or refute acupuncture for neuropathic pain in general or for any specific neuropathic pain condition.

Reviews of acute zoster

Qi and colleagues, at Chengdu University of Traditional Chinese Medicine, pooled trials of acupuncture against Western medicine. They report a higher “total effective rate”, a responder scale common in Chinese trials, fewer people developing PHN (odds ratio 0.07, 95% confidence interval 0.02 to 0.21), and shorter times to pain relief and scabbing. Pain scores on a visual analogue scale did not differ significantly between groups.

He and colleagues, at Zhejiang Chinese Medical University, pooled six trials of electroacupuncture added to or compared with routine treatment, which in most trials was the antiviral valaciclovir with B vitamins. They report lower pain scores, a shorter time until the rash cleared and fewer cases of PHN with electroacupuncture, and no difference in adverse reactions. They found publication bias and called the inferences weak because the trials were small, varied in design and uneven in quality. Five of the six trials needled Huatuojiaji (EX-B2), the points beside the spine that this catalogue codes by level, from XB02C1 to XB02S5; two of them added TB06 (Zhigou) and SI03 (Houxi). Electroacupuncture describes the method.

Liang and colleagues compared acupuncture-related treatments with drugs and with one another in a Bayesian network meta-analysis, which ranks treatments using direct and indirect comparisons. Against drug treatment, electroacupuncture combined with pricking and cupping ranked first for pain scores, electroacupuncture with fire needling ranked first for response rate, and pricking and cupping alone ranked first for preventing PHN. The authors called for more high-quality trials.

Reviews of postherpetic neuralgia

A 2018 review by Wang and colleagues at Guang’anmen Hospital in Beijing defined PHN as pain lasting three months after the rash and found seven trials with 647 people, all in China and all comparing acupuncture with drugs. None compared acupuncture with sham or no treatment, and none blinded participants or outcome assessors. Two trials could be pooled, and they reported pain scores 1.80 points lower on a 0 to 10 scale with acupuncture. The authors found no evidence of an advantage on global impression or quality of life, and called the results inconclusive because of the trials’ low quality.

A 2019 review by Pei and colleagues in Guangzhou searched to July 2018 and included eight trials, six published in Chinese. Controls were drugs such as carbamazepine, indomethacin and pregabalin; one Cuban trial used sham electroacupuncture with ketamine. It reported lower pain intensity with acupuncture overall and in subgroups of electroacupuncture, fire needling and bloodletting with cupping, and rated the pain result moderate certainty on GRADE. The authors explain that they did not downgrade for the lack of blinding, because blinding was hard to achieve when the groups received different kinds of treatment.

A 2023 network meta-analysis by Cui and colleagues in Harbin included 29 trials with 1,973 people. In direct comparisons, every acupuncture-related treatment reduced PHN pain more than antiepileptic drugs such as gabapentin and pregabalin; across the network, pricking and cupping added to antiepileptics ranked first for pain. Fewer adverse events were reported with acupuncture-related treatment than with antiepileptics.

An overview of reviews by Xia and colleagues, published in 2025 and searched to August 2022, assessed seven systematic reviews of PHN covering 128 trials and 9,792 people. On AMSTAR 2, a checklist for how well a review was conducted, most were low or critically low. Of 32 outcomes graded, 9 were high certainty, 5 moderate, 1 low and 17 very low. The comparison of bloodletting with drug treatment showed the least heterogeneity, with a mean pain difference of 2.80 points. Six reviews reported safety, and none recorded a serious adverse event. Bloodletting describes pricking and cupping.

Two individual trials

The VZV Pain Study, run by Ursini and colleagues at Pescara General Hospital in Italy and published in 2011, randomised 102 people with intense or very intense acute zoster pain to eight sessions of acupuncture over four weeks or to standard pain treatment: pregabalin, with buprenorphine or oxycodone for severe pain. Both groups received antivirals where prescribed, and the trial was open-label. In the 66 people analysed, response rates were 81.6% with acupuncture and 89.2% with drugs, and PHN at three months was 48.4% and 46.8%; none of the differences was significant. No serious treatment-related adverse event occurred.

In the second, a 2026 trial in JAMA Neurology by Chen and colleagues at seven hospitals in China, 448 people aged 45 to 75 with moderate to severe PHN received 20 sessions over four weeks of electroacupuncture or a sham. The real group was needled on the affected side at TB06, which the paper writes as SJ6, at GB34 (Yanglingquan) and at tender ashi points 2 to 3 cm apart around the painful area, with a 2 Hz current. The sham used blunt needles that did not pierce the skin, with the electrodes attached and the current blocked. At four weeks pain had fallen by 1.52 points on a 0 to 10 scale with electroacupuncture and 0.99 with sham, a difference of 0.53 points. The authors set 1.5 points as the minimal important difference, the smallest change patients notice, and the difference fell below it. Responders, people whose pain fell by 30% or more, were 46.7% against 24.3%, and the difference held at the eight-week follow-up. Bruising at the needle site was the main side effect. The trial did not test whether blinding held, and the sham group lost twice as many people. Sham acupuncture sets out the kinds of sham in use and why none is inert.

What guidelines say

The US Centers for Disease Control and Prevention’s clinical overview names acyclovir, valacyclovir and famciclovir as the preferred antivirals, most effective within 72 hours of symptom onset, and recommends two doses of the recombinant zoster vaccine for adults 50 and older and for adults 19 and older with weakened immune systems. It does not mention acupuncture. The German S2k guideline on zoster and postherpetic neuralgia, in its 2020 edition, covers antiviral treatment, pain management and vaccination and does not mention acupuncture either.

For neuropathic pain in general, the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain updated its recommendations in a 2025 review in Lancet Neurology, limited to double-blind, placebo-controlled trials of drugs and of non-invasive neuromodulation such as transcranial magnetic stimulation. It recommends tricyclic antidepressants, gabapentinoids and serotonin-noradrenaline reuptake inhibitors first-line, capsaicin patches and cream and lidocaine plasters second-line, and botulinum toxin, repetitive transcranial magnetic stimulation and opioids third-line. Its recommendations name no acupuncture treatment.

In China, a 2025 expert consensus published in Chinese Acupuncture & Moxibustion sets out recommendations on nine clinical questions for fire needling in acute zoster and PHN, alone and combined with cupping, herbs, filiform needles or moxibustion. Clinical guidelines compares how guideline bodies treat acupuncture across conditions.

What the reviews could not settle

For acute zoster, every pooled comparison set acupuncture against drugs or added it to them in open trials, and the Italian trial found no difference from standard pain treatment, so no review could separate the needling from the attention and expectation around it. The reviews disagree on pain itself: Qi and colleagues found no significant difference in pain scores while He and colleagues found one. The reported falls in PHN rest on small trials, mostly from Chinese databases, and the Italian trial found PHN rates of nearly half in both arms. For PHN, the one large sham-controlled trial found a difference smaller than the threshold its own authors set for importance, followed people for four weeks after treatment, and enrolled only people in China, which its authors name as a limit on generalising it. The overview found most reviews of low or critically low quality, and no Cochrane review has examined acupuncture for zoster or PHN.

AcuiQ’s symptom pages for herpes zoster, acute herpes zoster, postherpetic neuralgia and postherpetic neuralgia pain list the protocols individual studies prescribed, each with its citation.