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Zahn C, Puga C, Malik A, Khanna D. Painful Raynaud's mimics. Best Pract Res Clin Rheumatol 2024; 38:101948. [PMID: 38704280 DOI: 10.1016/j.berh.2024.101948] [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: 03/30/2024] [Accepted: 04/04/2024] [Indexed: 05/06/2024]
Abstract
Raynaud's syndrome is a common finding in many autoimmune conditions. Accurately diagnosing Raynaud's, and differentiating it from mimicking conditions, is imperative in rheumatologic diseases. Raynaud's syndrome and Raynaud's mimickers, especially painful Raynaud's mimickers, can prove a diagnostic challenge for the practicing rheumatologist. Painful Raynaud's mimickers can lead to increased patient stress and unnecessary medical work up; Healthcare providers need to be aware of Raynaud's mimickers when evaluating patient concerns of skin color changes and pain. The present narrative review aims to highlight Raynaud's syndrome, important painful mimickers that may be seen, diagnosis, and updated management recommendations.
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Affiliation(s)
- Carleigh Zahn
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, 300 North Ingalls Building - Rm 7C27, Ann Arbor, MI, 48109, USA.
| | - Cindy Puga
- Cedars Sinai Internal Medicine Residency, 8700 Beverly Blvd, Becker Bldg. B105 A, Los Angeles, CA, 90048, USA.
| | - Aroosa Malik
- Department of Internal Medicine, Division of Vascular Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Dinesh Khanna
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, 300 North Ingalls Building - Rm 7C27, Ann Arbor, MI, 48109, USA.
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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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Bourkas AN, Geng R, Sibbald M, Sibbald RG. A case of erythromelalgia with gastrointestinal dysautonomia treated with immunoglobulin: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231213137. [PMID: 38022850 PMCID: PMC10658769 DOI: 10.1177/2050313x231213137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/01/2023] [Indexed: 12/01/2023] Open
Abstract
An 18-year-old female with a history of atopic march, hyperhidrosis, and eosinophilic esophagitis was diagnosed with erythromelalgia and gastrointestinal dysautonomia secondary to presumed autoimmune small fiber neuropathy. The patient experienced significant clinical improvements after the initiation of intravenous immunoglobulin therapy, supporting an underlying autoimmune disorder.
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Affiliation(s)
| | - Ryan Geng
- Temerty School of Medicine, University of Toronto, Toronto, ON, Canada
| | - Matthew Sibbald
- Department of Medicine, McMaster Education Research Innovation and Theory (MERIT) Program, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - R Gary Sibbald
- Dalla Lana School of Public Health & Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Michelerio A, Tomasini C, Arbustini E, Vassallo C. Clinical Challenges in Primary Erythromelalgia: a Real-Life Experience from a Single Center and a Diagnostic-Therapeutic Flow-Chart Proposal. Dermatol Pract Concept 2023; 13:e2023191. [PMID: 37557164 PMCID: PMC10412061 DOI: 10.5826/dpc.1303a191] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION Primary erythromelalgia (EM) is a rare clinical syndrome characterized by recurrent erythema, burning pain and warmth of the extremities. The symptoms greatly compromise the patients' quality of life leading to severe disability. SCN9A mutations can be the cause of the disease. Dermatologists are often the specialists these patients turn to for assistance. OBJECTIVES To describe the demographic and clinical characteristics of patients with primary EM, to assess the presence and mutation types in the SCN9A gene, to evaluate the effectiveness of several therapeutic approaches, and to propose a diagnostic algorithm with therapeutic implications. METHODS A monocentric retrospective study using the database of patients with a discharge diagnosis of primary EM of our Center. Demographic, clinical, instrumental and laboratory data of patients were reviewed. RESULTS Eleven female patients (age range 16 to 57) were selected. All patients were affected in both the lower and upper extremities. Follow-up ranged from 2 to 9 years. Four patients had four different heterozygous variants of the SCN9A gene. Two patients, although genetically negative, had a suggestive family history. A variety of medications were tried in all our patients to alleviate symptoms, but their efficacy was variable, partial and/or transitory. The most effective therapies were antihistamines, venlafaxine, and mexiletine. CONCLUSIONS The diagnosis and treatment of EM remain challenging. Patients with this condition display a wide spectrum of clinical manifestations and severity, as well as a paucity of resources and structures to support them. Mutations in the SCN9A gene are not always detected.
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Affiliation(s)
- Andrea Michelerio
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Dermatology Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlo Tomasini
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Dermatology Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Eloisa Arbustini
- Centre for Inherited Cardiovascular Diseases, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Camilla Vassallo
- Dermatology Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Ma JE, Lee JUJ, Sartori-Valinotti JC, Rooke TW, Sandroni P, Davis MDP. Erythromelalgia: A Review of Medical Management Options and Our Approach to Management. Mayo Clin Proc 2023; 98:136-149. [PMID: 36470753 DOI: 10.1016/j.mayocp.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/21/2022] [Accepted: 08/16/2022] [Indexed: 12/05/2022]
Abstract
Erythromelalgia (EM) is a rare disorder characterized by episodic, burning pain associated with erythema and warmth of the extremities. The feet and hands are most commonly affected. The pain can be so severe that patients may engage in behaviors, sometimes extreme, to cool the affected areas and change their lifestyle to avoid precipitating factors, such as exercise and increased ambient heat. A literature search was performed with PubMed and MEDLINE with the search term erythromelalgia. Inclusion criteria were studies on EM published after 1985 until January 1, 2022, in the English language and studies that provided information on medical treatment of EM. Studies were excluded if they were duplicates or did not include treatment data. No guidelines exist for the treatment of this complex disorder. Lifestyle modifications and pharmacologic treatments (topical and systemic) are discussed in this article, which provides a comprehensive review of published medical management options for erythromelalgia and a proposed approach to management.
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Affiliation(s)
- Janice E Ma
- Division of Dermatology, Harbor-UCLA Medical Center, Torrance, CA
| | - Jinnee U J Lee
- Chicago Medical School, Rosalind Franklin University, North Chicago, IL
| | | | - Thom W Rooke
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Mayo Clinic Gonda Vascular Center, Rochester, MN
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Considerations for lactation with Ehlers-Danlos syndrome: a narrative review. Int Breastfeed J 2022; 17:4. [PMID: 34983567 PMCID: PMC8725515 DOI: 10.1186/s13006-021-00442-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022] Open
Abstract
Background Ehlers-Danlos syndrome (EDS) is a rare genetic connective tissue condition that is poorly understood in relation to lactation. As diagnostic methods improve, prevalence has increased. EDS, a disorder that impacts connective tissue, is characterized by skin extensibility, joint hypermobility, and fragile tissue which can affect every organ and body system leading to complications during pregnancy, delivery, and the postpartum period. Traits of this disease can cause mild to severe physiologic and functional obstacles during lactation. Unfortunately, there is little clinical evidence and minimal guidance for lactation management, and providers may feel uncomfortable and hesitant to address these concerns with patients due to a lack of readily available resources on the subject and inexperience with such patients. This narrative review describes and discusses the types of EDS, identifying symptoms, considerations, and precautions for care providers to implement during lactation and breastfeeding. Methods An electronic search of relevant citations was conducted using the databases Cochrane, PubMed, and Google Scholar from 1 January 2000 to 1 November 2021. Search terms used were Ehlers-Danlos syndrome, Hypermobility Syndrome, breastfeeding, lactation, breastmilk expression, breastmilk collection, human milk expression, human milk collection, and infant feeding. The search of these databases yielded zero results. As no research articles on EDS were directly related to lactation, this narrative review includes articles found that related to the health of mothers relevant to maternal function during lactation. Discussion For the healthcare provider, identifying characteristics of EDS can improve the management of lactation challenges. Mothers may experience generalized symptoms from gastrointestinal distress to fatigue or chronic pain, while they also may suffer from more specific joint complaints and injuries, such as dislocations / subluxations, or skin fragility. Such obstacles can generate impediments to breastfeeding and create unique challenges for breastfeeding mothers with EDS. Unfortunately, new mothers with these symptoms may have them overlooked or not addressed, impacting a mother’s ability to meet her breastfeeding intentions. While there are some published research manuscripts on EDS and pregnancy, there is a lack of information regarding breastfeeding and lactation. Additional research is needed to help guide EDS mothers to achieve their breastfeeding intentions.
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Dusch M, Schmelz M. [Erythromelalgia: skin redness and pain]. Schmerz 2019; 33:475-490. [PMID: 31485751 DOI: 10.1007/s00482-019-00401-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Erythromelalgia is a rare disease that is associated with hemato-oncological diseases or after taking certain drugs and toxins, but it can also occur as an independent clinical picture, for example, due to mutations in the sodium channel NaV1.7. Clinically, there is a characteristic triad of attack-like burning pain and skin redness in the area of the distal extremities, which can be alleviated by excessive cooling. The attacks are triggered by heat, exertion, and stress. The diagnosis is primarily made clinically and can be confirmed by genetic testing if a sodium channel NaV1.7 mutation is present. Important differential diagnoses are complex regional pain syndrome, the non-freezing cold injury, and small fiber neuropathies. Therapy is multidisciplinary and has to be planned individually and include physical therapy and psychotherapy as well as drug therapy as integral components.
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Affiliation(s)
- M Dusch
- Klinik für Anästhesiologie und Intensivmedizin, Fachbereich Schmerzmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - M Schmelz
- Abteilung Experimentelle Schmerzforschung, CBTM, Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
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Hussain S, Nissen S, Holland SM, Sandroni P, Lionakis MS. Treatment of Posaconazole-Induced Peripheral Neuropathy With Methylprednisolone and Magnesium Infusions: A Case Report. Open Forum Infect Dis 2019; 6:ofz031. [PMID: 31312664 DOI: 10.1093/ofid/ofz031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 01/30/2019] [Indexed: 11/14/2022] Open
Abstract
The tolerability of long-term posaconazole use remains poorly defined. We present a patient who developed peripheral neuropathy following long-term exposure to the tablet formulation of posaconazole, which was treated with methylprednisolone and magnesium infusions. The potential role of methylprednisolone and magnesium infusions in managing this potentially irreversible triazole-associated complication requires further study.
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Affiliation(s)
- Sadia Hussain
- Critical Care Medicine Department, National Institutes of Health (NIH) Clinical Center, Bethesda, Maryland
| | - Susan Nissen
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Health Systems, Faribault, Minnesota
| | - Steven M Holland
- Immunopathogenesis Section, Laboratory of Clinical Immunology & Microbiology (LCIM), National Institute of Allergy and Infectious Diseases (NIAID), NIH, Bethesda, Maryland
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
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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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Al-Minshawy SM, El-Mazary AAM. An Egyptian child with erythromelalgia responding to a new line of treatment: a case report and review of the literature. J Med Case Rep 2014; 8:69. [PMID: 24568362 PMCID: PMC3943265 DOI: 10.1186/1752-1947-8-69] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 01/06/2014] [Indexed: 12/21/2022] Open
Abstract
Introduction Erythromelalgia is a rare clinical syndrome characterized by episodic erythema, warmth and intense burning pain, which commonly involves the extremities. For those affected, this disorder may lead to significant long-term morbidity. Unfortunately, to date, no definitive therapy is available. This case report describes an Egyptian child with primary erythromelalgia that manifested at an early age and showed partial response to therapy with cetirizine hydrochloride. This anecdotal case report may have a diagnostic value for clinicians who have not seen this disorder. Case presentation A 34-month-old previously healthy right-handed Hamitic boy without any significant past medical history presented at the age of 2 years with episodic bilateral pain in his feet. His mother reported associated warmth and erythema localized to his feet that never extended beyond his ankle joints. This pain is triggered by exertion and/or warm temperature exposure and is relieved by cooling measures. The diagnosis of erythromelalgia was made based on the patient’s medical history and a thorough physical examination during the episodes. No evidence of local or systemic infection was present. Other causes for the symptoms were excluded by a negative extensive diagnostic work-up. Our patient did not respond to ibuprofen (15mg/kg/dose) three times a day but partial improvement with the oral non-sedating antihistaminic cetirizine hydrochloride (2.5mg/kg/once daily) was observed. When the child stopped cetirizine hydrochloride for 1 month as a test, the symptoms became aggravated and were relieved when cetirizine therapy was restarted. Cetirizine hydrochloride had not previously been reported to have this effect in children with erythromelalgia. Conclusions Erythromelalgia is a clinical syndrome of which the etiology, diagnosis and management are controversial. We describe a case of a 34-month-old Egyptian child with primary erythromelalgia that manifested at an early age. We believe that this is the first Egyptian case report of this kind in the literature. Partial response of this patient to cetirizine hydrochloride may grant us a new clue to understanding this mysterious condition.
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Tokarz KA. Patient education and self-advocacy: queries and responses on pain management; erythromelalgia. J Pain Palliat Care Pharmacother 2009; 23:295-7. [PMID: 19670025 DOI: 10.1080/15360280903099067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Questions from patients concerning a disease process known as erythromelalgia, its diagnosis, symptoms, and treatments are answered to help patients and caregivers understand the disease and its treatment. The responses from the author are intended to educate patients about their disease and make them more effective self-advocates.
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Delye H, Lagae L, Vermylen J, Nuttin B. Thalamic stimulation as a treatment for primary erythromelalgia: technical case report. Neurosurgery 2006; 57:E404; discussion E404. [PMID: 16234658 DOI: 10.1227/01.neu.0000176703.27632.6d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE AND IMPORTANCE We report the use of bilateral thalamic stimulation in a case of primary erythromelalgia with immediate and important pain relief for 3 years. CLINICAL PRESENTATION A 12-year-old boy experiencing primary erythromelalgia had a 4-year history of recurrent attacks of severe burning pain in both feet, accompanied by local reddening, swelling, and heating of the skin. The attacks were triggered by warmth and exercise. The pain was relieved only by elevation and cooling of the lower limbs, which he achieved by immersing his legs in a bucket of ice water, resulting in severe ulceration of the skin. INTERVENTION Because of the gradual aggravation of the signs and symptoms and resistance of the patient's condition to several medical therapies, the patient received spinal cord stimulation. The implants were removed twice because of recurrent infection. Finally, the patient was treated with bilateral electrical stimulation of the ventral posterolateral thalamic nucleus, which resulted in important pain control until 3 years later. The patient was able to avoid water immersions, and all ulcerations disappeared. CONCLUSION We conclude that thalamic stimulation was successful in this case of primary erythromelalgia.
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Affiliation(s)
- Hans Delye
- Department of Experimental Neurosurgery and Neuroanatomy, Katholieke Universiteit, Leuven, Belgium
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Abstract
No treatment is consistently effective in the management of patients with erythromelalgia. There is a dearth of adequate studies examining the response of erythromelalgia to treatment. Most recommendations are suggested based on case reports, small case series, and anecdotal reports. The management of erythromelalgia is difficult and frequently involves a multidisciplinary approach. An approach to management of individuals with erythromelalgia includes patient education, learning to avoid episodes, relieving discomfort of the episodes, controlling secondary and underlying factors, and use of drugs used to control erythromelalgia.
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Affiliation(s)
- Mark D P Davis
- Department of Dermatology and the Gonda Vascular Center, Mayo Clinic and Mayo Foundation, 200 First Street, SW, Rochester, MN 55905, USA.
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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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Abstract
No treatment is consistently effective in the management of patients with erythromelalgia. There is a dearth of adequate studies examining the response of erythromelalgia to therapy. Most recommendations are suggested based on case reports, small case series, and anecdotal reports. The management of erythromelalgia is difficult and frequently involves a multidisciplinary approach. An approach to management of individuals with erythromelalgia includes patient education, learning to avoid episodes relieving discomfort of the episodes, controlling secondary and underlying factors, and use of drugs used to control erythromelalgia.
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Affiliation(s)
- Mark D. P. Davis
- Department of Dermatology and the Gonda Vascular Center, Mayo Clinic and Mayo Foundation, 200 First Street, SW, Rochester, MN 55905, USA.
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