| Summary: | Background: Postherpetic neuralgia (PHN) remains the most frequent and distressing sequela of herpes zoster (HZ). Although psychological factors are known to contribute to chronic pain, their role during the acute phase of HZ in predicting PHN has not been fully clarified. This study aimed to investigate whether acute-phase anxiety is independently associated with subsequent PHN development and to evaluate the added predictive value of anxiety assessment in clinical prediction models. Methods: This longitudinal cohort study enrolled 99 patients with acute HZ between January 2022 and January 2025. Anxiety was assessed at baseline using the Hospital Anxiety and Depression Scale-Anxiety subscale (HADSA) and the State-Trait Anxiety Inventory-State subscale (STAI-S). PHN was defined as pain lasting at least 90 days after rash onset. We performed logistic regression to identify independent predictors and constructed receiver operating characteristic (ROC) curves to evaluate predictive performance. Results: The 3 months incidence of PHN was 41.4% (41/99). Patients who developed PHN had significantly higher baseline HADS-A scores (10.7 ± 3.8 vs. 6.4 ± 3.2, p < 0.001) and STAI-S scores (52.8 ± 10.4 vs. 41.3 ± 9.7, p < 0.001) than those who did not. Multivariate analysis identified three independent predictors: age (adjusted odds ratio [OR] = 1.47 per 10 years, p = 0.038), baseline pain intensity (adjusted OR = 1.41, p = 0.012), and HADS-A score (adjusted OR = 1.31 per unit, p = 0.001). Clinically significant anxiety (HADS-A ≥ 8) was associated with a 4.52-fold increased risk of PHN (95% confidence interval: 1.72–8.58, p = 0.013). HADS-A demonstrated good discriminative ability (area under the curve [AUC] = 0.813), and a combined model incorporating anxiety with clinical variables achieved superior predictive performance (AUC = 0.876 vs. 0.762, p = 0.019). Conclusions: Acute-phase anxiety is an independent and clinically meaningful predictor of PHN. Adding anxiety assessment to clinical evaluation significantly improves risk prediction accuracy, supporting routine psychological screening and early intervention in patients with HZ.
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