RSD Puzzle #043

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

BOARD CERTIFIED IN ELECTROMYOGRAPHY

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

RSD PUZZLE # 43
THE POSSIBLE LOSS OF FINGERNAILS AND TOENAILS IN RSD PATIENTS

Many thanks for your FAX letter dated 3/12/96. The question regarding the loss of fingernails or toenails in RSD patients is not an uncommon occurrence. However, it is uncommon for the patient to lose 8 fingernails at a time. Regardless, even if the patients loses all the fingernails at one time, they do grow back. There are multiple factors that cause the loss of fingernails.

The two most critical factors are the combination of ischemia or constriction of blood vessels in the hands or feet due to the application of ice or due to the repetitive exposure to cold. the second factor is the flair-up of inflammation of RSD usually due to a distressful condition causing recurrence of a new attack of RSD. This flair-up cause inflammation and poor circulation to the fingernails. The third factor contributing to the loss of finger or toenails is the disturbance of the immune system which is usually part and parcel of the inflammatory aspect of the RSD. As a result, the patient develops fungal infection on top of the poor circulation.

SUGGESTIONS:

1. The use of Epsom salt and almost hot water on a frequent basis. The Epsom salt being hyperosmolar magnesium sulfate saturates the extracellular space with magnesium. This secondarily works as a calcium channel blocker, and improves the function of the nerves in the skin and subcutaneous tissue helping the nerve to regrow. As a matter of fact, Epsom salt and hot water should be the daily routine for treatment of RSD and should totally replace the harmful damage of cold water exposure.

2. Exercise in any way, shape, or form be it crumbling newspaper with the hand, walking for the feet, the use of play doh, silly putty, rubber ball, tennis ball, etc. this improves the surface circulation or the hand and prevents constriction of the blood vessels and poor circulation to the root of the fingernails and toenails. In this regard, the use of warm paraffin is also helpful.

3. The use of Clonidine patch 0.1 to 0.2 mg to be applied at the lower cervical spine level at C-7 -T-1 level in the posterior aspect of the cervical spine. This type of nerve block opens up the circulation the circulation in the hands.

4. If the patient has not had nerve blocks recently, the nerve blocks will be very helpful for this condition. Especially, axillary nerve blocks are very helpful for this condition. The axillary nerve blocks are so effective and so low risk that we have practically completely replace the stellate ganglion blocks with axillary nerve blocks.

5. If at the time the doctor instructs the patient to use Clonidine patch over the lower cervical spine region, pressure on that are shows reddish discoloration of the skin due to the secretion of substance P, that area should be treated with paravertebral and epidural nerve block as well.

Once the fingernails start growing, then the patient should be taking a course of antifungal medication by mouth (one tablet of Nizoral daily for 7 days) either at the onset of the above plan of treatment or once the fingernails start growing.

H.Hooshmand, M.D.

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