Dermatological findings in early detection of complex regional pain syndrome

Atypical dermatologic manifestations in complex regional pain syndrome: a case report

BACKGROUND

Complex regional pain syndrome is a chronic pain condition characterized by autonomic dysfunction, changes in sympathetic and vasomotor activity, and sensory and motor changes. Complex regional pain syndrome is a clinical diagnosis and may occur after trauma or surgery. Complex regional pain syndrome-related pain may occur spontaneously and is out of proportion with the inciting event. We report herein the rare case of a man who developed concomitant painful generalized ulcerations after diagnosis of complex regional pain syndrome.

CASE PRESENTATION

A 43-year-old Caucasian male with history of four-extremity complex regional pain syndrome type 2 secondary to right rotator cuff surgery performed at an outside hospital presented to a tertiary care center for treatment of generalized ulcerations on all extremities of unknown etiology. Dermatology performed an extensive work-up including laboratory evaluations and biopsies, which were relatively unremarkable. His ulcers were treated with vinegar-based dressings, hydrotherapy, and irrigation and debridements. He was started on methadone (replacing a home fentanyl patch), ketamine infusion, and amitriptyline in addition to his home adjuncts. He obtained good symptom control, improved sleep, and diminished cognitive slowing, compared with his fentanyl patches.

CONCLUSION

This case report emphasizes an atypical case of generalized ulceration formation in the setting of complex regional pain syndrome. This case highlights the challenging nature of treating complex regional pain syndrome and using multimodal analgesia to target various nociceptive receptors to successfully reduce symptoms.

Complex Regional Pain Syndrome: The Importance of Early Diagnosis

Complex regional pain syndrome (CRPS) is a potentially life-altering, neuropathic pain condition that often affects an extremity in response to surgery or even minor trauma. The pain is often disproportionate to the injury sustained or the surgical procedure performed-and it has been described as excruciating and unbearable. CRPS can result in irreversible, disabling changes in the affected limb. In some cases it has resulted in amputation or severe psychological issues. However, CRPS outcomes are generally more successful with early detection and treatment. This article presents an overview of CRPS and discusses the critical role nurses can play in recognizing the condition early, assisting with treatment, and providing psychological support.

Lightning-Storm Periungual Capillaries in a Patient with Complex Regional Pain Syndrome Type I

Introduction

Complex regional pain syndrome (CRPS) is characterized by chronic pain out of proportion to injury following trauma. CRPS most commonly results after crush-type injury to the hand and may be associated with various cutaneous symptoms believed to be driven by vasomotor instability. Existing reports in the literature have employed a range of methodologies to describe and evaluate cutaneous and vascular changes in CRPS, though there exists no current gold standard for diagnosis.

Case Presentation

Here, we report a 71-year-old male with a 10-year history of CRPS who presented with abnormal capillaries on onychoscopy, demonstrating a "lightning-storm" pattern.

Conclusion

Previous studies have shown increased blood flow to the cutis in the early stage of CRPS, yet diminished cutaneous flow during the later stages. However, one study showed increased nail capillary diameter in patients with later stage CRPS. Due to a variety of reported clinical characteristics and a nonspecific clinic presentation, both the recognition and diagnosis of CRPS is difficult. Nail fold capillaroscopy may be a useful and accessible tool for evaluating patients with CRPS.