Pain Management Center
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H. Hooshmand, M. D.
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RSD PUZZLE #126
CRPS (RSD) and Pruritus
Many thanks for your most recent letter regarding persistent itching in a patient who is suffering from CRPS (RSD).
There are certain interesting features about this patient.
1. In regard to migrating pruritus, this condition points to the spread of sympathetic dysfunction to the other extremities. Please refer to RSD Puzzle #18, which discusses the spread of CRPS (RSD). It also has 15 different references regarding the spread of CRPS (RSD).
2. In regard to the relationship of inflammation, I would suggest that you tap the Med-line for references under CRPS (RSD) and Plasticity. It will provide you with priceless information regarding the relationship of CRPS (RSD) to inflammation. In 1995, there was an excellent article in the Journal of Clinical Neuropharmacology. This was in the form of a review of the subject of CRPS (RSD) by Dr. H. Ollat and Dr. P. Cesaro from Paris. They have an excellent review of the principle of plasticity in CRPS (RSD). As you are well aware, the principle of plasticity refers to the fact that in any disease, when the condition becomes chronic, it effects the DNA of the cells that are supposed to repair damaged areas. The areas then become permanently effected. The genetic coding of the cells, be it nerve cells or white blood cells, becomes distorted. As a result, the patient's tissues will not have the plasticity to heal the damaged area. This is especially true in regard to the calcium magnesium pump, sodium potassium pump, and NMDA role in the cell membrane stability.
As you are well aware, the sympathetic system has three major functions.
1. Control of the body temperature.
2. Control of vital signs; B/P, pulse and respiration.
3. Regulation of the immune system.
In the first two years after the development of CRPS (RSD), the immune system is up regulated with high T cell lymphocytes causing low grade fever, neurodermatitis, trophic ulcers, spontaneous bruising, edema, clinical pictures of compression (entrapment), neuropathies such as so-called carpal tunnel syndrome and thoracic ulcer syndrome, which can easily be corrected with conservative treatment rather than surgical treatment.
After two years, as the CRPS (RSD) becomes chronic and the healing power (plasticity) of the nervous system and immune system becomes disturbed, the patient develops hypoactive, down regulated immune system with development of permanent elevation of killer T cell lymphocytes, suppression of helper T cell lymphocytes, and development of persistent skin pathology, such as persistent edema involving the paraspinal and upper and lower extremities, persistent pruritus and neurodermatitis, persistent trophic ulcers, spontaneous bruising, permanent dystrophic changes in regard to skin healing, and abnormal hair and nail growth.
I will summarize the course of treatment, as follows:
1. Treatment with IV Mannitol (Please refer to the following RSD Puzzles 111, 112,115 regarding I.V. Mannitol). It is old, from early 1970's, but they apply as much now as they did then. The principle is that one should not use extra-cellular diuretics for the edema of CRPS (RSD), because it only makes it worse by stimulating the sympathetic system with the stress of dehydration. Mannitol is an intra-cellular diuretic and, as such, gets rid of the edema and itching without stimulating the sympathetic system.
2. Treatment with ACTH. I have written a chapter on the subject of ACTH in my text book titled "Chronic Pain: Reflex Sympathetic Dystrophy - Prevention and Management" published by CRC Press in Boca Raton, FL. Prednisone and Decadron should not be used because the dermatologic conditions are chronic and the use of Prednisone or Decadron on a chronic basis causes serious complications such as adrenal atrophy, and other well known complications.
3. The use of epsom salt and warm water, or the use of magnesium sulfate enema or magnesium sulfate laxatives, all increase the extra-cellular magnesium level, and as such act as an effective calcium channel blocker reducing the inflammation in the dermal, and peripheral nervous system structures. An epsom salt bath is very effective in this condition. The opposite, and one of the most destructive ways of treating this condition, would be the application of ice. That only increases allodynia and raises constriction with aggravation of edema and itching.
4. The use of IV immunoglobulin in more severe and advanced cases is very effective.
5. For the symptomatic relief of the itching, treatment with two benzodiazepines which are non-addicting, and do not suppress the endobenzodiazepines, and help the problem of pruritus tremendously. These consist of:
I. Serax 50 mg q6h prn.
II. Klonopin 0.5 mg 1/2-1 tablet q6h prn.
Obviously, both benzodiazepines should not be used on the same patient.
6. One of the most important aspects of the treatment of the disturbance of the immune system with manifestations of pruritus, trophic ulcer, etc, is to detoxify the patient from medications that suppress cerebral endorphins and cerebral endo BZ's (endobenzodiazepines). The first group of these medications consists of morphine sulfate, MS Contin, methadone, Tylox, Codeine, Percodan, Percocet, Lortab, Demerol, and any other morphine agonist. These should be discontinued as fast as possible. They should be replaced with Buprenex, which the researchers at Harvard University state can be used to detoxify heroin, cocaine and morphine addicts within the first 24-48 hours. If Buprenex is not practical, the other alternatives would be Stadol or Ultram, or alternating the two of them.
For the endo BZ agonist problem (the use of benzodiazepine that are addicting such as Xanax, Ativan, Valium, Restoril or Ambien), the patient can be treated with Serax or Klonopin, as mentioned above.
7. The last, but not least, form of treatment is treatment with analgesic type of anti-depressants which do not cause obesity (such as Elavil, which has a tendency to cause obesity and fatigue), and do not have other serious sexual side effects. These consist of two main medications:
I. Trazodone 50-300 mg qhs. Trazodone provides good REM sleep as well, which is very important for management of chronic pain.
II. Desipramine 25-75 mg qhs, which also provides excellent pain control and good rest and sleep at night.
8. Diet is also very important because certain foods such as chocolate, hot dogs, cold cuts and sausage aggravate the condition. (Please refer to the 4F-Diet)
I hope the above will be of some help to you.
H. Hooshmand, M.D.
1.Ollat H, Cesaro P: Pharmacology of neuropathic pain. Clin Neuropharmacol 1995;18:391-404.
2.Ling E, Wesson DR, Charuvastra C, et al: A controlled trial comparing buprenorphine and methadone, maintenance in opioid dependence. Arch Gen Psychiatry 1996; 53:401-7.
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