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Caldito EG, Caldito NG, Kaul S, Piette W, Mehta S. Erythromelalgia. Part II: Differential diagnoses and management. J Am Acad Dermatol 2024; 90:465-474. [PMID: 37364616 DOI: 10.1016/j.jaad.2023.02.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 06/28/2023]
Abstract
The management of erythromelalgia is challenging and requires multidisciplinary effort. Patient education is crucial as unsafe self-administered cooling techniques can lead to significant morbidity, including acral necrosis, infection, and amputation. The goal of management is pain control, reduction of flare frequency, and prevention of complications. This text is focused on the management of erythromelalgia and several other incompletely understood and under-recognized neurovascular disorders such as red scrotum syndrome, red ear syndrome, facial flushing, and complex regional pain syndrome.
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Affiliation(s)
| | | | - Subuhi Kaul
- Division of Dermatology, John H Stroger Hospital of Cook County, Chicago, Illinois
| | - Warren Piette
- Division of Dermatology, John H Stroger Hospital of Cook County, Chicago, Illinois; Department of Dermatology, Rush University Medical Center, Chicago, Illinois
| | - Shilpa Mehta
- Division of Dermatology, John H Stroger Hospital of Cook County, Chicago, Illinois.
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2
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Rodrigues LM, Caetano J, Andrade SF, Rocha C, Alves JD, Ferreira HA. Studying Erythromelalgia Using Doppler Flowmetry Perfusion Signals and Wavelet Analysis-An Exploratory Study. Biomedicines 2023; 11:3327. [PMID: 38137548 PMCID: PMC10741181 DOI: 10.3390/biomedicines11123327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/09/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
Erythromelalgia (EM) is a rare disease, which is still poorly characterized. In the present paper, we compared the hand perfusion of one female EM patient, under challenges, with a healthy control group. Using a laser Doppler flowmeter (LDF) with an integrated thermal probe, measurements were taken in both hands at rest (Phase I) and after two separate challenges-post-occlusive hyperemia (PORH) in one arm (A) and reduction of skin temperature (cooling) with ice in one hand (B) (Phase II). The final measurement periods corresponded to recovery (Phases III and IV). The control group involved ten healthy women (27.3 ± 7.9 years old). A second set of measurements was taken in the EM patient one month after beginning a new therapeutic approach with beta-blockers (6.25 mg carvedilol twice daily). Z-scores of the patient's LDF and temperature fluctuations compared to the control group were assessed using the Wavelet transform (WT) analysis. Here, fluctuations with |Z| > 1.96 were considered significantly different from healthy values, whereas positive or negative Z values indicated higher or lower deviations from the control mean values. Cooling elicited more measurable changes in LDF and temperature fluctuations, especially in higher frequency components (cardiac, respiratory, and myogenic), whereas PORH notably evoked changes in lower frequency components (myogenic, autonomic, and endothelial). No significant Z-score deviations were observed in the second measurement, which might signify a stabilization of the patient's distal perfusion following the new therapeutic approach. This analysis involving one EM patient, while clearly exploratory, has shown significant deviations in WT-derived physiological components' values in comparison with the healthy group, confirming the interest in using cold temperature as a challenger. The apparent agreement achieved with the clinical evaluation opens the possibility of expanding this approach to other patients and pathologies in vascular medicine.
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Affiliation(s)
- Luis Monteiro Rodrigues
- CBIOS—Research Center for Biosciences and Health Technologies, Universidade Lusófona Lisboa, 1700-097 Lisbon, Portugal; (J.C.); (S.F.A.); (C.R.)
| | - Joana Caetano
- CBIOS—Research Center for Biosciences and Health Technologies, Universidade Lusófona Lisboa, 1700-097 Lisbon, Portugal; (J.C.); (S.F.A.); (C.R.)
- Immuno-Mediated Systemic Diseases, Medicina IV, Hospital Fernando Fonseca, 2720-276 Amadora, Portugal;
- Nova Medical School, Nova University of Lisboa, 1169-056 Lisboa, Portugal
| | - Sergio Faloni Andrade
- CBIOS—Research Center for Biosciences and Health Technologies, Universidade Lusófona Lisboa, 1700-097 Lisbon, Portugal; (J.C.); (S.F.A.); (C.R.)
| | - Clemente Rocha
- CBIOS—Research Center for Biosciences and Health Technologies, Universidade Lusófona Lisboa, 1700-097 Lisbon, Portugal; (J.C.); (S.F.A.); (C.R.)
| | - José Delgado Alves
- Immuno-Mediated Systemic Diseases, Medicina IV, Hospital Fernando Fonseca, 2720-276 Amadora, Portugal;
- Nova Medical School, Nova University of Lisboa, 1169-056 Lisboa, Portugal
| | - Hugo Alexandre Ferreira
- Faculty of Sciences, Institute of Biophysics and Biomedical Engineering, University of Lisbon, Campo Grande, 1749-019 Lisboa, Portugal;
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Tham SW, Giles M. Current pain management strategies for patients with erythromelalgia: a critical review. J Pain Res 2018; 11:1689-1698. [PMID: 30214279 PMCID: PMC6121769 DOI: 10.2147/jpr.s154462] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Erythromelalgia (EM) is a rare disorder characterized by erythematous, warm, painful extremities, which is often precipitated by cold conditions. The pathophysiology of EM is incompletely understood. Recent investigations have identified sodium channelopathy as a genetic cause for this pain condition, classified as primary inherited EM. Other subtypes are idiopathic EM and secondary EM. The management of pain in EM is challenging as no single therapy has been found to be effective. There is varying response to pharmacotherapy and significant variability within this clinical population, resulting in a stepwise trial and error approach. Consequently, EM is often associated with poorer health-related quality of life with higher morbidity. There is currently no consensus or guidelines on management of pain in EM. This is a review of the literature on management of pain using pharmacologic, procedural intervention and nonpharmacologic treatment in children and adults with EM.
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Affiliation(s)
- See Wan Tham
- Seattle Children's Research Institute, Seattle, WA, USA,
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA,
| | - Marian Giles
- Seattle Children's Research Institute, Seattle, WA, USA,
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA,
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Kundu A, Rafiq M, Warren PS, Tobias JD. Erythromelalgia in the pediatric patient: role of computed-tomography-guided lumbar sympathetic blockade. J Pain Res 2016; 9:837-845. [PMID: 27799815 PMCID: PMC5079692 DOI: 10.2147/jpr.s110688] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Erythromelalgia (EM) is an uncommon condition characterized by erythema, increased skin temperature, and burning pain, most frequently occurring in the lower extremities. The pain is generally very severe and treatment can be extremely challenging, especially in the pediatric and adolescent population. We report a series of three cases of primary EM in pediatric patients involving the lower extremities, refractory to medical treatment that responded favorably to computed-tomography-guided lumbar sympathetic blockade. There was a significant improvement in pain scores, quality of life, and overall function as well as decreased analgesic requirements. Lumbar sympathetic blockade should be considered as a therapeutic modality in pediatric and adolescent patients with EM who are refractory to other treatments.
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Affiliation(s)
- Anjana Kundu
- Department of Anesthesiology, Dayton Children's Hospital, Dayton
| | | | | | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine; Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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5
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Patel N, Chen E, Cucchiaro G. The Complexity of Pain Management in Patients with Erythromelalgia. ACTA ACUST UNITED AC 2016; 5:151-3. [PMID: 26528699 DOI: 10.1213/xaa.0000000000000201] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 15-year-old girl diagnosed with erythromelalgia was admitted to the hospital with severe pain in her feet associated with burning, pruritus, erythema, and swelling. She had not responded to conventional management and received some relief only from cold bath immersions, which resulted in chronic blistering and multiple episodes of superinfection. After a successful trial of spinal cord stimulation, she had a permanent implantation procedure. The spinal cord stimulator relieved her pain and improved function but not the sensation of burning pain. However, this pain resolved after she started daily mexiletine. This case demonstrates that erythromelalgia sometimes can be managed successfully with a combination of pharmacologic and interventional procedures.
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Affiliation(s)
- Neha Patel
- From the *Department of Anesthesiology, and †Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Bouyahyaoui Y, Meziane M, Hanaae Z, Mikou O, Mernissi FZ, Baba Khouya A, Otmani S, Hida M. [Primary familial erythromelalgia. A case report]. Arch Pediatr 2013; 20:369-71. [PMID: 23433844 DOI: 10.1016/j.arcped.2013.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 10/08/2012] [Accepted: 01/19/2013] [Indexed: 01/13/2023]
Abstract
Erythromelalgia is a rare disease whose etiology is poorly understood. It is characterized by paroxysmal attacks of erythema, pain, and warmth of the extremities and can be primary or secondary. We report a case of primary familial erythromelalgia and stress the difficulties in its therapeutic management. We provide a brief update on the pathophysiology and treatment of primary erythromelalgia.
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Elgueta F, de la Cuadra-Fontaine JC, Clede L, Fierro C, Valderrama A. Erythromelagia: A Rare and Hard-to-Treat Condition: A 9-Year-Old Boy Responsive to Intravenous Lidocaine and Oral Mexilitene. PAIN MEDICINE 2013; 14:311-2. [DOI: 10.1111/pme.12030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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8
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Nardi A, Damann N, Hertrampf T, Kless A. Advances in targeting voltage-gated sodium channels with small molecules. ChemMedChem 2012; 7:1712-40. [PMID: 22945552 DOI: 10.1002/cmdc.201200298] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 07/30/2012] [Indexed: 12/19/2022]
Abstract
Blockade of voltage-gated sodium channels (VGSCs) has been used successfully in the clinic to enable control of pathological firing patterns that occur in conditions as diverse as chronic pain, epilepsy, and arrhythmias. Herein we review the state of the art in marketed sodium channel inhibitors, including a brief compendium of their binding sites and of the cellular and molecular biology of sodium channels. Despite the preferential action of this drug class toward over-excited cells, which significantly limits potential undesired side effects on other cells, the need to develop a second generation of sodium channel inhibitors to overcome their critical clinical shortcomings is apparent. Current approaches in drug discovery to deliver novel and truly innovative sodium channel inhibitors is next presented by surveying the most recent medicinal chemistry breakthroughs in the field of small molecules and developments in automated patch-clamp platforms. Various strategies aimed at identifying small molecules that target either particular isoforms of sodium channels involved in specific diseases or anomalous sodium channel currents, irrespective of the isoform by which they have been generated, are critically discussed and revised.
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Affiliation(s)
- Antonio Nardi
- Global Drug Discovery, Department of Medicinal Chemistry, Grünenthal, Zieglerstrasse 6, 52078 Aachen, Germany.
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Morales PS, Escobar RG, Lizama M, Aglony M, Salomon J, Drenth JPH, Borzutzky A. Paediatric hypertension-associated erythromelalgia responds to corticosteroids and is not associated with SCN9A mutations. Rheumatology (Oxford) 2012; 51:2295-6. [DOI: 10.1093/rheumatology/kes098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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10
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Abstract
Level of Evidence: V, Expert Opinion
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Affiliation(s)
- Timothy C Beals
- University of Utah Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108, USA.
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Iqbal J, Bhat MI, Charoo BA, Syed WA, Sheikh MA, Bhat IN. Experience with oral mexiletine in primary erythromelalgia in children. Ann Saudi Med 2009; 29:316-8. [PMID: 19584578 PMCID: PMC2841462 DOI: 10.4103/0256-4947.55316] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Primary erythromelalgia is characterized by burning pain, redness, and warmth in the extremities. We present two cases of primary erythromelalgia both of whom presented with a history of several months of severe burning pain in both hands and feet. Both patients had received multiple pain medications with no improvement in symptoms. Pain was relieved by putting affected parts in ice cold water, which resulted in immersion injury of the affected parts. Both patients stopped taking part in school and social activities. We tried oral mexiletine, a class Ib antiarrythmic agent, in view of its reported role in various chronic painful conditions. Dramatic improvement was observed with its use. Both patients improved after several weeks of use, and there were fewer soaking episodes. We observed no adverse effects with mexilitine therapy.
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Affiliation(s)
- Javeed Iqbal
- Department of Pediatrics and Neonatology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir 190019, India.
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Paticoff J, Valovska A, Nedeljkovic SS, Oaklander AL. Defining a Treatable Cause of Erythromelalgia: Acute Adolescent Autoimmune Small-Fiber Axonopathy. Anesth Analg 2007; 104:438-41. [PMID: 17242106 DOI: 10.1213/01.ane.0000252965.83347.25] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Conditions described as "erythromelalgia" and "erythermalgia" are being formally specified by etiological diagnoses that enable the use of disease-modifying as well as symptomatic treatments. We describe an otherwise healthy 20-year-old man with acute-onset erythromelalgia. Severe bilateral distal limb pain and vasodilation persisted despite the use of many antihyperalgesics. Pathological examination of cutaneous nerve endings revealed severe small-fiber predominant axonopathy. Treatment of his apparent autoimmune polyneuropathy with high dose corticosteroids, 4 days of lidocaine infusion, and a prednisone taper cured him. Similarities to other cases allowed us to tentatively characterize a new treatable cause of erythromelalgia; acute adolescent autoimmune small-fiber axonopathy. In this report we evaluate various options for diagnosis and treatment.
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Affiliation(s)
- Joshua Paticoff
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Drenth JPH, te Morsche RHM, Guillet G, Taieb A, Kirby RL, Jansen JBMJ. SCN9A mutations define primary erythermalgia as a neuropathic disorder of voltage gated sodium channels. J Invest Dermatol 2005; 124:1333-8. [PMID: 15955112 DOI: 10.1111/j.0022-202x.2005.23737.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Primary erythermalgia is a rare disorder characterized by recurrent attacks of red, warm and painful hands, and/or feet. We previously localized the gene for primary erythermalgia to a 7.94 cM region on chromosome 2q. Recently, Yang et al identified two missense mutations of the sodium channel alpha subunit SCN9A in patients with erythermalgia. The presence of voltage-gated sodium channels in sensory neurons is thought to play a crucial role in several chronic painful neuropathies. We examined four different families and two sporadic cases and detected missense sequence variants in SCN9A to be present in primary erythermalgia patients. A total of five of six mutations were located in highly conserved regions. One family with autosomal dominantly inherited erythermalgia was double heterozygous for two separate SCN9A mutations. These data establish primary erythermalgia as a neuropathic disorder and offers hope for treatment of this incapacitating painful disorder.
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Affiliation(s)
- Joost P H Drenth
- Department of Medicine, Division of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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Nathan A, Rose JB, Guite JW, Hehir D, Milovcich K. Primary erythromelalgia in a child responding to intravenous lidocaine and oral mexiletine treatment. Pediatrics 2005; 115:e504-7. [PMID: 15741349 DOI: 10.1542/peds.2004-1395] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Erythromelalgia is a rare, chronic, debilitating condition characterized by redness, warmth, and severe burning pain of the distal extremities. The feet are more commonly affected than the hands. Pain is precipitated by increases in temperature and by exercise. Patients often obtain relief by immersing the affected extremity in cold water. The pain is often refractory to treatment. For many patients, multiple pain medications have been useless in achieving complete relief of pain symptoms. Previous reports of erythromelalgia among adolescents indicated prolonged relief of pain with sodium nitroprusside infusions, epidural infusions of local anesthetics, or gabapentin treatment. We present a case of an 11-year-old, white, male child with primary erythromelalgia, whose initial symptoms started in his preschool years and whose childhood was marked by escalating episodes of pain with warmth and redness of his feet, precipitated especially by increases in temperature and by activity. All conventional pain management techniques had failed to relieve our patient of his symptoms, and he obtained some relief only by soaking his affected extremities in ice water. He had experienced minimal benefit from seeing a pain psychologist, who helped him develop techniques to cope with the pain. At the time of presentation, the patient's episodes of pain had increased to 15 to 20 per day, and there was evidence of chronic immersion injury to the skin of his feet. Before his most recent hospitalization, the pain had spread to involve his hands as well. The patient was overwhelmed with anxiety and could not participate in school or social activities at the time of admission. During his current hospitalization, he did show some therapeutic response to sodium nitroprusside infusion, which unfortunately had to be discontinued because of side effects and because his family desired to leave the ICU environment, which was stressful to the patient. He also had some response to lumbar epidural infusion of local anesthetics, which could not be continued because he found the motor blockade that accompanied his analgesia intolerable. However, intravenous lidocaine infusion, with subsequent transition to oral mexiletine therapy, proved very effective in reducing the frequency and severity of the pain episodes. The patient was discharged from the hospital with oral mexiletine therapy and has been monitored at the pain management clinic. He returned to and completed school, attended summer camp, and enjoys an active happy life. He walks without precipitating pain in his feet and sleeps 9 to 10 hours every night. He has needed to soak his feet on only 4 occasions in the 6 months since his discharge from the hospital. His quality of life has improved significantly. He has shown no evidence of liver toxicity, and his mexiletine levels have been stable.
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Affiliation(s)
- Aruna Nathan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Jeffcoate WJ, Idris I, Game FL. Erythromelia, or Mitchell's syndrome--new names for unexplained signs of inflammation in distal symmetrical neuropathy in diabetes. Diabet Med 2004; 21:1334-8. [PMID: 15569137 DOI: 10.1111/j.1464-5491.2004.01346.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Two cases are described in which distal symmetrical sensorimotor neuropathy complicating diabetes was associated with episodes of subacute vasodilation of one or other lower limb, and which were otherwise unexplained. The vasodilation was associated with swelling and stiffness, but was painless and self-limiting. INTERPRETATION It is suggested that this phenomenon results from disordered vasoregulation in diabetic neuropathy, and is linked to the processes which underlie diabetic neuropathic osteoarthropathy (Charcot foot), as well as disorders such as complex regional pain syndrome-1 (CRPS-1, reflex sympathetic dystrophy) and erythromelalgia. CONCLUSIONS As self-limiting vasodilation may be not uncommon in distal symmetrical neuropathies, but unrecognized because the phenomenon has not been named, the terms 'neuropathic erythromelia' or 'Mitchell's syndrome' are proposed. The adoption of either of these names may lead to earlier diagnosis and prevent inappropriate investigation and treatment.
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Affiliation(s)
- W J Jeffcoate
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, City Hospital, Nottingham, UK.
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Roth S, Tieulié N, Hummelsberger M, Sanderson F, Heudier P, Fuzibet JG. [Regressive erythema: an uncommon progression during HIV infection]. Presse Med 2004; 33:102. [PMID: 15026703 DOI: 10.1016/s0755-4982(04)98496-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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