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RSD PUZZLE #90
RSD AND TREATMENT OF TROPHIC ULCERS
To Whom It May Concern:
At the request of the patients, I am writing a protocol of treatment. The patient has
developed trophic ulcers over the extremities. RSD has been diagnosed by the patient's
physicians.
Trophic ulcers are not unusual in RSD, being a sympathetic nervous system
dysfunction, manifests itself as follows:
1. Hyperpathic and allodynic pain ( pain accompanied by change in vital signs, sweating
and pain that becomes worse with simple touch or a breeze).
2. The response to the pain is in the form of motor response the spinal cord resulting in
constriction of blood vessels, cold extremities, muscle spasm, tremor and flexion
deformity.
3. Disturbance of the immune system. The sympathetic system regulates the immune system.
The sympathetic system is responsible for control of body temperature, control of vital
signs and control of the immune system. Any kind of stress that stimulates the sympathetic
system, also stimulates the immune system.
This disturbance of the immune system manifests in inflammation, spontaneous bruising and
black and blue spots over the skin, neurodermatitis, edema and swelling that mimics
conditions such as carpal tunnel and tarsal tunnel syndrome. In addition, the immune
system disturbance in more severe cases not only cause neurodermatitis, but also cause
trophic ulcers. Trophic ulcers usually develop after treatment with cast immobilization,
wheelchair immobilization, surgical treatment or application of ice. At, times, the
trophic ulcer and immune system disturbance are caused by incomplete pain management.
Once trophic ulcers develop, the following should be the protocol of treatment:
1. Treatment with IV Mannitol 100 grams in 1000 cc D5W.
2. Treatment with Decadron Dose-Pack for one week.
3. After one week, the Decadron Dose Pack should be replaced with IM ACTH, which does not
cause suppression of adrenal cortical function and instead stimulates the adrenal gland to
secrete it's own cortical steroids. The ACTH should be given 40 units IM twice a week,
along with the patient taking some form of antacid, such as Zantac or Cimetidine on a
daily basis ACTH will be continued in 12-20 weeks.
4. Epsom salt and warm water bath. The magnesium sulfate works as an hyperostotic agent.
It reduces swelling and inflammation. In addition, magnesium sulfate increases the level
of serum magnesium and acts as a calcium channel blocker, helping the healing of the cells
in correcting the inflammation.
5. Most importantly, the pain should become under control. In the regard, addicting
narcotics are contraindicated. they can cause withdrawal (rebound) pain, which is a s
harmful as the original pain cause by the disease.
I am enclosing a list of controlled and non-controlled drugs. As is noted, Class V, which
is totally not controlled, non-addicting and contains medications such as aspirin,
Tylenol, etc., and also includes Buprenex. Buprenex has been used for years to help in
detoxification of Heroine, Methadone, Morphine, and Cocaine addicts. Buprenex has no
tendency for drug dependence and no tendency for withdrawal pain or tolerance.
Whereas the neuropathic pain usually does not respond properly to treatment with
endorphins, it responds quite nicely to treatment with Buprenex, which is a morphine
antagonist.
If the patient cannot take Buprenex, then Stadol NS or Nubain would be the other, less
preferred, morphine antagonist.
6. Even more important than analgesics for control of pain, is the use of analgesic type
anti-depressants. Ideally, Desipramine 25 mg bid and 50 mg qhs can be used. Anafranil and
Tofranil should not be used because they cause obesity, fatigue and drop of blood pressure
and pulse.
Another very effective analgesic/ antidepressant is Trazodone at the dosage of 50 to 300
mg daily, which does have the above mentioned side effects of tricyclic anti-depressants.
The dose should start at 50 mg at bedtime and every night an extra 50 mg should be added,
until the pain is so well under control that the patient can sleep eight hours a night.
7. The area of ulcers should be treated not only with epsom salt and warm water bath, but
also with Maalox liquid alternated Zonalon (Sinequan) cream and alternated with
corticosporin lotion.
8. None of the above treatments will work unless the patient stays very active and
exercises as much as possible. The reason being the lack of exercise causes stimulation of
the chemoreceptors in the extremities and it aggravates the pain and inflammation.
9. Any use of ice or surgical procedures should be absolutely avoided.
H. Hooshmand, M.D.
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