ERYTHROMELALGIA ----------------------------------------------------- I have a 60 y.o. male with a one-year history of erythromelalgia confined to the feet. The pt. does not have an elevated platelet count. He has hypertension, controlled with beta blockers. Calcium channel blockers worsened his erythromelalgia symptoms as noted in the literature. Aspirin and other NSAIA's had no effect. Pushing beta blockers had no effect. Any suggestions for treatment? Ethan D. Nydorf, M.D. --------------------- I have had great sucess with 40% urea in aquaphor. Bob Aylesworth M.D. ------------------- It sounds like the patient might have a Trental deficiency. Haines Ely MD ------------- I have been a silent observer for a few months and have found the discussions interesting and occasionally helpful (esp IRBD). It takes a while to become comfortable with this modality - but the potential for good is great. Yesterday, I saw an 18 year-old woman with burning tender feet for two to three weeks. She's in good general health; a college student active in dance and cheerleading, she takes no medications other than OCP. The exam showed bright red warm feet, no papules or plaques, hands were normal. No edema. I suspect this is erythromelalgia (sometime called erythermelalgia) and can only remember seeing one similar case in the distant past. Three textbooks painted different pictures - not surprising since this is realtively rare. I obtained cbc and chemistries and ua (since thrombocythemia, diabetes and a host of other disease have been associated); held off on any more esoteric studies - recommended elevation, cold compresses and ASA 650 mg qid and will see her back in a week. May use an NSAID if ASA is not helpful. Does this picture suggest any other diagnosis (we see chilblains here commonly, and this looks quite different) and has anyone treated a number of these patients - and what seems to work best? Thank you for your help. David J. Elpern -------------------- Your address (Hawaii) seems to rule against cold induced diseases such as erythromelalgia. The most common cause of what you are seeing is a mixed corynebacterial infection in sweaty feet. The best treatment is a month or so of erythromycin, orally. Careful exam of the hands usually reveals some fingertip erythema and desquamation as well. Haines Ely -------------------- Quick search lead to piroxicam rx (JAAD l991-Jan), propranolol rx, and I was wondering about Trental as a possibility? Note that it has been associated with SLE and as a sign of internal malignancy- Diane Thaler -------------------- Haines, would you say keratolysis exfoliativa is corynebacterium as well? What do you use in people who cannot tolerate erythro? And why do some people get it only in the late Fall through Winter-at least here in cold country. If David's patient does have erthromelalgia, what do you think of Trental rx? Diane Thaler -------------------- No suggestion for other dxs. However, an elderly woman (already on aspirin) complained of burning feet. Exam showed increased erythema otherwise normal. KOH was neg. Tried Zostrix cream and warned of burning sensation with application. Patient thrilled!! Burning of feet completely resolved within one week. Currently tapering, so do not know if "cured" or controlled by Zostrix cream. Mary K. Cullen -------------------- I suggest "neuropeptidogenic acral dermatitis" as described in the International Journal of Dermatology by Italian Dermatologists several years ago. Zostrix was very useful. Robert I. Rudolph, M.D., FACP -------------------- There is a condition called symmetric lividities of the feet. I'm sure it was described in the JAAD about 1987. I've seen it several times usually in young males who are very active in sports. Your patient may have this condition. James G. Rothschild -------------------- The proper name is acral neuropeptidogenic dysesthesia. Robert I. Rudolph, M.D., FACP -------------------- If ASA not helpful, would consider something like Zyrtec to treat this as possible pressure urticaria(?from the dancing and cheerleading?) Hal Rehbein -------------------- Excerpt from Rook's Textbook of Dermatology on CD-Rom "Diffuse erythematous eruptions/Scarlatiniform eruptions Scarlatiniform eruptions (Fig 41-8 . The known causes include the exotoxins of the haemolytic streptococcus and staphylococcus causing scarlet fever, and certain drugs (Chapters 23 and 74). The onset is usually acute and the eruption may be generalized or it may be restricted to localized areas, e.g. the palms and soles. There is a diffuse erythema which may be associated with a burning sensation in the skin and sometimes some itching. There may be fever and variable systemic symptoms. Spontaneous resolution usually occurs in 10-21 days and is often followed by desquamation. There may also be shedding of nails and sometimes of hair. In those cases where no cause is detected recurrences are not infrequent. The presence of an exanthem helps to distinguish scarlet fever from other scarlatiniform eruptions but is not completely reliable. Intradermal injections of a specific streptococcal antitoxin will cause blanching of the erythema in scarlet fever (Schultz-Charlton test), a test now very seldom used." Erythermalgia occurs in short attacks precipitated by heat which would seem to exclude it from the diagnosis Philip Bekhor -------------------- Diane, I'm writing the next in the series of my Cutis articles on this very topic. Keratosis exfoliativa is corynebacterial, but it comes on in October and May more than any other months. SO deos herpses zoster. I have pondered this timing for 20 years. WHy? Maybe som one smart on the list knows the answer. As to erythromelalgia: I like Trental, DIltiazem, and a baby aspirin in combination. Of course, keeping warm is the best bet. Haines Ely -------------------- I have treated several patients with erythromelalgia. Assuming a negative systemic workup, I have had success with combination therapy using beta blockers, trental and tricyclic antidepressants. This in patients who have failed aspirin therapy. Ethan D. Nydorf, M.D. -------------------- I'd like to thank those who gave me advice on the young woman with erythromelalgia. I saw her back yesterday (after five days) and to my surprise she is symptom free on ASA 650 mgs qid. Feet no longer hot, slight erythema. Labs normal. I'm surprised this was so simple, but improvement may have nothing to do with medications. My second choice based on advice and readings would have been to add periactin. The suggestion of a localized scarletiniform eruption was interesting, and reaction to bacterial exotoxin similar to that seen with TSS and SSSS should have been considered. What I learned: 1) It's erythermalgia not erythromalgia 2) There's primary erythromelalgia, secondary erythromelalgia and erythermalgia. Much more complicated than I thought. Medline had 48 references in the past 3 years. David J. Elpern -------------------- Erythromelalgia/erythermalgia Caper: In the Lancet, 1990: Vol 336, pp 183-4, JJ Michiels made the following observation: "The erythromelalgia patient finds: warmth intensifies discomfort a single dose of aspirin gives complete relief for several days the patient has a chronic myoproliferative disease with thrombocytopenia. platelet clumping leads to thrombi in the small vessels with resultant acrocyanosis and finally necrosis. "The erythermalgia patient experiences the same redness and burning pain of the extremities brought on by heat or exercise, but by contrast finds: no response to aspirin no progression to necrosis" The conclusion: "Watch your vowels or you'll get the diagnosis wrong. " See also JAAD 1989, Vol 21, pp 1128-30 on Idiopathic erythermalgia. Jerry Litt --------------------