Trigeminal trophic syndrome: an updated review

Trigeminal trophic syndrome: A systematic review

OBJECTIVES

To systematically report and document Trigeminal Trophic Syndrome (TTS), characterize its clinical presentation, diagnostic tests performed, outline management strategies, outcomes; and highlight the role of otolaryngologists in the tissue diagnosis of this rare syndrome.

DATA SOURCES

PubMed/Medline, Scopus, and Cochrane databases.

REVIEW METHODS

PubMed/Medline, Scopus, and Cochrane databases were systematically reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all cases of TTS published with an English translation from inception to December 2020.

RESULTS

A total of 142 articles describing 214 patients with TTS were included in the analysis. There was a female predominance (62.9 %) and a median age of 57 (range 1-93) years at presentation. A trigeminal neurological insult was identified in 200 (93.5 %) cases. The most common triggers for TTS were treatment for trigeminal neuralgia (35.7 %) and cerebrovascular accident (21.6 %). Self-inflicted trauma occurred in 137 (64 %) patients. Biopsy was done in 123 (57.5 %) patients. Patient education, barrier devices, and medications to address parasthesias were the most common treatment strategies. The majority of patients (72.5 %) received multimodal therapy. Surgery was performed in 35 (22.7 %) patients. Treatment outcomes were discussed in 120 (56.1 %) patients.

CONCLUSIONS

TTS is a rare condition with poorly understood pathophysiology. It should be suspected in a patient with non-healing facial ulceration and altered sensation within the trigeminal nerve distribution. Biopsy of the ulcer is important to confirm the diagnosis and exclude malignancy. Treatment options include conservative and pharmacologic measures, and less frequently surgery.

Approach to the Atypical Wound

The heterogeneity of atypical wounds can present diagnostic and therapeutic challenges; however, as the prevalence of atypical wounds grows worldwide, prompt and accurate management is increasingly an essential skill for dermatologists. Addressing the underlying cause of an atypical wound is critical for successful outcomes. An integrated approach with a focus on pain management and patient engagement is recommended to facilitate enduring wound closure. Advances in treatment, in addition to further research and clinical training, are necessary to address the expanding burden of atypical wounds.

Trigeminal Trophic Syndrome: An Exuberant Case

N/a.

Crossroads of Neurodermatology: Trigeminal Trophic Syndrome

A 98-year-old female, with a past medical history of trigeminal neuralgia (TN) and non-melanoma skin cancer, presented with a crescent-shaped ulcer on her right nasal ala that had been present for months. On exam, the patient was aware of her issue, readily admitted to manipulation of the area, and had a past medical history significant for TN. The patient's history and clinical presentation led to a diagnosis of trigeminal trophic syndrome (TTS). TTS is an extremely rare, ulcerative condition that can arise in patients suffering from TN. While TN itself is well-documented, treatment is often challenging and usually focused on achieving symptomatic relief; for this patient, she did not achieve adequate management of her neuropathic symptoms, and her condition progressed to TTS. Thus, given the patient's ongoing multi-modal TN treatment, she was encouraged not to pick or manipulate the area to the best of her ability to curb the extent of ulceration. Given that TTS is so infrequently seen, we are hopeful that, by identifying the specifics of the underlying neuronal aberrancies in the future, we may be able to better grasp TTS's pathophysiology, ulcer development, and potential future treatment options.

Unilateral non-healing ulcers in zosteriform pattern

Trigeminal trophic syndrome (TTS) is a rare disease that occurs after injury to the trigeminal nerve. Though this condition has been reported in the early 20th century, it is still a rare entity, with only around 200 cases reported so far. It characteristically presents with persistent facial ulceration with loss of sensation and paraesthesia along the distribution of the trigeminal nerve. We here report a case of TTS developing as a complication of herpes zoster, which possibly occurred due to the nerve damage caused by varicella-zoster virus.

Trigeminal trophic syndrome associated with neuralgia after ischemic stroke-a case report

Trigeminal trophic syndrome (TTS) is a rare condition resulting from self-manipulation of the skin after an injury to the trigeminal nerve. We describe the case of a 70-year-old woman who was hospitalized because of erythema, ulceration, and crusts on the right side of her face, accompanied by itching, burning, and irritation forcing self-manipulation of the skin. She had been previously repeatedly treated with antibiotics, acyclovir, and topical medications without any improvement. Her medical history revealed an episode of ischemic stroke in 2016, after which a deformation and partial atrophy of the right ala nasi appeared. Trigeminal neuropathy was confirmed by a neurological consultation. Diagnosis and treatment of TTS requires a multidisciplinary approach. Awareness of this disease should be raised to enable proper diagnosis and management of difficult-to-treat facial ulcers that cannot be explained by common causes.

Trigeminal trophic syndrome in a pediatric patient with diffuse intrinsic pontine glioma

A 13-year-old girl with a history of diffuse intrinsic pontine glioma (DIPG) suffered from progressively worsening facial ulcerations secondary to paresthesia-induced self-excoriation. She was diagnosed with trigeminal trophic syndrome (TTS) induced by DIPG and struggled to heal her lesions in the background of this excoriation disorder. A multidisciplinary approach that included mood disorder management with sertraline and amitriptyline helped diminish paresthesia, improve her quality of life, and promote healing of the ulcers despite the progression of her DIPG. This case highlights the multifactorial complexity of TTS in pediatric patients and the need for successful management strategies.

Postherpetic Trigeminal Trophic Syndrome: A Case Report

Trigeminal trophic syndrome (TTS) is a rare condition characterized by anesthesia, paresthesia, and facial ulceration involving the trigeminal dermatome secondary to self-manipulation of the skin after a peripheral or central injury to the trigeminal nerve or its branches. Differential diagnosis of TTS includes conditions presenting with chronic facial ulceration, such as various infectious diseases, malignancy, vasculitis, pyoderma gangrenosum and dermatitis artefacta. We report a case of postherpetic TTS and highlight the importance of early diagnosis and prompt treatment of this condition, which may commonly be misdiagnosed.

A rare case of a folded nasolabial flap for a full-thickness alar defect due to trigeminal trophic syndrome after herpes zoster infection

A 51-year-old man was referred for a skin defect with paresthesia and decreased pain in his right ala. He had a history of herpes zoster infection 3 weeks previously. Excisional biopsy and culture showed no evidence of skin malignancy or infection. He was diagnosed with trigeminal trophic syndrome (TTS) after herpes zoster infection. A two-stage folded nasolabial flap was used to reconstruct the defect. The patient was satisfied with the cosmetic outcomes of surgery, and there was no evidence of recurrence during the follow-up. TTS, a rare skin condition that presents with paresthesia, anesthesia, and facial ulceration, occurs after trigeminal nerve injury, which can be caused by herpes zoster infection in rare cases. TTS is an often-persistent condition with a high recurrence rate, causing cosmetic problems. Some surgical methods have been attempted, but our case presents the first use of a folded nasolabial flap to treat TTS. The flap was symmetric, without any nostril collapse. It is also noteworthy that the outcome was excellent with only a skin flap that did not use a bony framework. Herein, we report a rare case of TTS that occurred after herpes zoster infection and was successfully treated with a folded nasolabial flap.

Unilateral ulcerations on the forehead and scalp

We describe a patient with unilateral ulcerations on the forehead and scalp, occurring 3 months after herpes zoster infection. Further investigations were unremarkable. Histology showed epidermal and upper dermal ulceration associated with a mild nonspecific dermal inflammatory infiltrate composed of lymphoid cells and histiocytes.

An innovative approach in the treatment of trigeminal trophic syndrome

BACKGROUND

Trigeminal trophic syndrome (TTS) is a rare disorder that presents as ulceration of the nasal ala, and less often ipsilateral cheek, cutaneous lip, and forehead, following damage to the trigeminal nerve. TTS is often very difficult to treat due to anesthesia and paresthesia along the distribution of the trigeminal nerve, which often leads to a large behavioral component of this disease.

METHODS

In this single case report, a thermoplastic mask was sutured in place overlying the chronic ulcerations of TTS in a 57-year-old man.

RESULTS

Significant re-epithelization of the chronic ulcerations of TTS was seen after only 6 weeks of thermoplastic mask attachment.

CONCLUSION

While TTS is a chronic and difficult to treat disease, the use of a thermoplastic mask in the treatment of this disease can significantly decrease the self-manipulation component and allow for re-epithelization and healing of the chronic ulcerations.

Cutaneous Neuroimmune Interactions in Peripheral Neuropathic Pain States

Bidirectional interplay between the peripheral immune and nervous systems plays a crucial role in maintaining homeostasis and responding to noxious stimuli. This crosstalk is facilitated by a variety of cytokines, inflammatory mediators and neuropeptides. Dysregulation of this delicate physiological balance is implicated in the pathological mechanisms of various skin disorders and peripheral neuropathies. The skin is a highly complex biological structure within which peripheral sensory nerve terminals and immune cells colocalise. Herein, we provide an overview of the sensory innervation of the skin and immune cells resident to the skin. We discuss modulation of cutaneous immune response by sensory neurons and their mediators (e.g., nociceptor-derived neuropeptides), and sensory neuron regulation by cutaneous immune cells (e.g., nociceptor sensitization by immune-derived mediators). In particular, we discuss recent findings concerning neuroimmune communication in skin infections, psoriasis, allergic contact dermatitis and atopic dermatitis. We then summarize evidence of neuroimmune mechanisms in the skin in the context of peripheral neuropathic pain states, including chemotherapy-induced peripheral neuropathy, diabetic polyneuropathy, post-herpetic neuralgia, HIV-induced neuropathy, as well as entrapment and traumatic neuropathies. Finally, we highlight the future promise of emerging therapies associated with skin neuroimmune crosstalk in neuropathic pain.

Trigeminal trophic syndrome: an important simulator of discoid cutaneous lupus erythematosus – a case series

Trigeminal trophic syndrome occurs secondary to trigeminal nerve injury, leading to anaesthesia and paraesthesia, with consequent vigorous facial skin manipulation and lesion production, simulating other facial diseases such as ulcerative discoid lupus erythematosus, tumours and other artificially produced lesions. Ulceration and destruction of the ala nasi is a typical feature besides scratching end excoriations in the cutaneous segment affected. In this series, we present the features of five patients with trigeminal trophic syndrome, highlighting possible confusion with cutaneous lupus. Differential diagnoses, including discoid lupus erythematosus, are discussed, as well as possible treatment modalities.

Trigeminal Trophic Syndrome Secondary to Refractory Trigeminal Neuralgia Treated with CyberKnife® Radiosurgery

Trigeminal trophic syndrome (TTS) is a rare condition in which there is the involvement of the skin innervated by branches of the trigeminal nerve. Because of an alteration in the sensory function of the trigeminal nerve, an exaggerated manipulation of the skin by the patient occurs, with secondary ulcers in the affected areas. They are usually unilateral and located mainly at the beginning of the nose wing. There are very few publications in the current literature, so it is in the interest of doctors to know this rare pathology.

Trigeminal Trophic Syndrome-A Unique Clinical Presentation of a Rare Condition

This study describes a unique clinical presentation of trigeminal trophic syndrome (TTS), which is not well described within the otolaryngology literature. Trigeminal trophic syndrome classically presents with a triad of symptoms: trigeminal anesthesia, facial paresthesias, and crescent-shaped ulceration of the lateral nasal ala. The patient discussed in this report had a self-induced, waxing and waning ulceration of the frontal scalp for 7 years and was evaluated and treated ineffectively by multiple physicians, including otolaryngologists, before TTS was diagnosed and a targeted treatment was initiated. Although extranasal presentation is uncommon, this condition must be considered when ulcers are encountered in the trigeminal dermatome. This case highlights the variability in presentation and the importance of awareness of this rare syndrome. We aim to facilitate more prompt diagnosis and expedite the initiation of appropriate treatment for TTS in the field of otolaryngology.