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A Look at the Dermatological Aspects of Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) is often misdiagnosed. Its localized edema is often mistaken as relating to other skin conditions. However, for patients with this chronic pain condition, proper treatment means relief from intense pain that only gets worse over time.

CRPS presents in three stages. It begins in the acute stage as burning or throbbing pain in 1 or more limbs with aching, and localized edema.  In this stage, a bone demineralization also occurs. After 2-3 months in stage 1, patients will see a progression of the soft-tissue edema, a sign of stage 2, the atrophic stage. The second stage typically lasts 3 to 6 months and is evident by muscle wasting, skin thickening, and development of brawny skin. The third stage, called the atrophic phase, includes trophic skin changes, ridged nails and, most severely, limitations of movement.

In a case report published in JAMA Dermatology, the patient was described as having as having a year-long problem of redness, swelling and burning in his left arm recurring up to 20-30 times a day.  Nothing in the patient’s clinical history showed possibility of thoracic outlet syndrome, multiple sclerosis, or other neurological diseases. He was diagnosed with complex regional pain syndrome and prescribed medications including tricyclic antidepressants, topic analgesics, local anesthetics, nonsteroidal anti-inflammatory drugs, and nitroglycerin 0.1% ointment for topical application. Doctors could not be sure what caused the condition, however most cases follow an inciting event such as soft-tissue injury, fractures, myocardial infraction, or cerebrovascular insults. This particular patient had been hit on the head and elbow by an overhead door two months before symptoms began.

According to the case report, in order to eliminate other potential disorders and prevent misdiagnosis, medical professionals should use autonomic testing and imaging studies. Bone scintigraphy, plain film radiography, and magnetic resonance imaging are a few studies that can helpful for diagnosis. Post-diagnosis treatment is only supportive. Pharmacologic measures can be utilized to help manage pain.

Early identification and management of complex regional pain syndrome is critical for favorable outcomes after diagnosis and treatment. It is important for dermatology providers to be able to recognize the signs and symptoms of CRPS in order to achieve these outcomes, minimize diagnostic error, and advance patient care.

Source: JAMA Dermatol. 2014;150(6):640-642. doi:10.1001

Image: Colin Davis

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