Category Archives: Erythromelalgia

Patching up Pain with a Lidocaine 5% Patch

Dear Pain Matters readers,

Treatment via a lidocaine 5% patch may offer significant pain relief for patients including cancer patients with focal nerve pain.

Specifically, patients with severe and localised nerve pain including one of the following painful conditions may benefit from a lidocaine 5% patch that topically delivers lidocaine:

  • Postherpetic neuralgia and herpes zoster (shingles);
  • Non-diabetic and diabetic peripheral neuropathy;
  • Trigeminal (orofacial) neuropathic pain;
  • Erythromelalgia;
  • Chronic low back pain (Hines et al, 2002);
  • Post-surgical neuropathic pain (e.g. following surgery for cancer or otherwise); and
  • Neuropathic pain directly attributable to cancer.

Lidocaine works by blocking sodium channels including Nav1.7 that underlie many nerve pain conditions (and other mechanisms).  The release of very small amounts of lidocaine transdermally via the patch ensures that motor and cardiac functions remain unaffected.

While topical lidocaine patches leads to pain relief in 29%-80% of treated patients, likely via small-fiber block, it is not clear why lidocaine patches may work better in some patients than in others (Krumova et al, 2012).

The topical lidocaine patch, measuring 10 cm X 14 cm, should only be applied on top of unbroken skin and where the pain is the greatest.  Patches should only be used by patients who are not allergic to local anaesthetics including lidocaine and who are not sensitive to the adhesive material itself.

The recommended maximum daily dose is 3 patches worn simultaneously for 12 hours at a time.  Since the lidocaine patch can only be worn for 12 hours at a time each day, other pain medications may be necessary, especially during sleep.

A Young Patient With Episodic Erythromelalgia In Both Feet

A 15-year old Caucasian girl who suffered disabling pain during episodes of erythromelalgia in both feet derived complete pain relief almost immediately after applying lidocaine 5% patches to the top of both of her feet, both at rest and during almost normal levels of activity.  

m_dce10009f2-3.png

Post-lidocaine patch treatment, the young patient was able to run around the track at school, play soccer, return to her physical education class, march in the school band and walk around the shopping mall for almost an hour.  As long as she did not overdo her activities, she was able to obtain 100% relief during the 12 hours of lidocaine patch use, plus another 2-3 hours after patch removal.  The patient slept without the patches.

Whilst offering complete local pain relief and no side effects, the lidocaine patch was unable to prevent the other symptoms of erythromelalgia from occurring including bright red skin and over-heated feet following physical exertion.

m_dce10009f1.png

(Davis & Sandroni, 2002, including both images).

Two (2) Patients With Neuropathic Pain Syndrome     

A 74-Year Old Female Patient With Herpes Zoster (Shingles)

Despite prompt treatment for a herpes zoster skin rash, a 74-year old woman developed stabbing and burning pain in her rash-affected area.  The patient was offered 2 lidocaine patches daily to cover the painful region.  Within 4 weeks treatment, the patient obtained 75% relief from pain caused by her herpes zoster skin rash.  Most of her systemic pain medications were stopped.

A 56-Year Old Male Patient With Severe Neuropathic Pain Syndrome Following Microsurgery For A Neuroma in Right Foot 

A 56-year old man suffered severe nerve pain shortly after microsurgery to his right foot due to an interdigital neuroma.  His painful symptoms included severe burning pain, mechanical hyperalgesia and allodynia, together with other symptoms.  As a result, he could no longer work, was unable to wear socks and shoes (only sandals) and withdrew from his family and friends.

After applying half of a lidocaine 5% patch daily onto his painful skin region, the patient reported positive results.  After 8 weeks of lidocaine patch treatment, the patient enjoyed an 80% reduction in overall pain levels and consequently returned to work.  There were no side effects and the patients was able to stop all other analgesics (Hans et al, 2010).

Trigeminal (Orofacial) Neuropathic Pain And Lidocaine Patch Treatment

A British study revealed that lidocaine 5% patch treatment led to improved pain levels in 12 of 14 trigeminal pain patients including oral surgery patients.  Nine (9) of the 12 patients were able to reduce or stop their intake of other pain medications.  Given that the majority (12/14) patients with trigeminal nerve pain benefited from lidocaine 5% patch treatment, further studies are warranted (Khawaja et al, 2013).

Cancer Patients And Lidocaine Patch Treatment

A large Australian study in a comprehensive cancer centre revealed that lidocaine 5% patch treatment had a ‘potent analgesic effect’ in 24 of 95 (25%) patients while another 23 patients (24%) reported a ‘partial effect’.  Given that almost half (47/95, or 49%) of all cancer patients with nerve pain benefited from lidocaine 5% patch treatment, further research is warranted (Fleming and O’Connor, 2009).

Current Study Involving Lidocaine Patch for Lower Limb Amputation Pain

A Belgium-based trial is currently recruiting up to 20 patients with pain following above- or below-knee amputation to assess the effectiveness of lidocaine patch treatment for peripherally-mediated phantom limb pain and/or stump scar hyperalgesia (Hatem, 2016).  Stay tuned for updates…

Summary

While lidocaine 5% patch treatment is expensive and there is a small risk of a skin rash, many patients with focal nerve pain obtain significant pain relief from the lidocaine 5% patch, a targeted peripheral analgesic that is non-addictive and safe for long-term use.  

Now that’s a good way to patch up pain!

Sabina Walker

Blogger, Pain Matters

REFERENCES

(1) Davis, Mark D P; Sandroni, Paola. Lidocaine Patch for Pain of Erythromelalgia; Arch Dermatol. Jan 2002;138(1):17-19

doi:10.1001/archderm.138.1.17

http://jamanetwork.com/journals/jamadermatology/fullarticle/478622

(2) Fleming JA, O’Connor BD.

Use of lidocaine patches for neuropathic pain in a comprehensive cancer centre.

(Utilisation des timbres de lidocaïne pour la douleur neuropathique dans un centre d’oncologie)

Pain Research & Management : The Journal of the Canadian Pain Society. 2009;14(5):381-388

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779156/#!po=28.7879

(3) Hans G, Robert D, Verhulst J, Vercauteren M. Lidocaine 5% patch for localized neuropathic pain: progress for the patient, a new approach for the physician. Clinical pharmacology : advances and applications. 2010;2:65-70

doi: 10.2147/CPAA.S9795

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3262358/

(4) Hines R, Keaney D, Moskowitz MH, Prakken S. Use of Lidocaine Patch 5% for Chronic Low Back Pain: A Report of Four Cases. Pain Med 2002; 3 (4): 361-365

doi: 10.1046/j.1526-4637.2002.02051.x

https://academic.oup.com/painmedicine/article-lookup/doi/10.1046/j.1526-4637.2002.02051.x

(5) Khawaja N, Yilmaz Z, Renton T. Case studies illustrating the management of trigeminal neuropathic pain using topical 5% lidocaine plasters. British Journal of Pain. 2013;7(2):107-113.

doi:10.1177/2049463713483459

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590123/#!po=23.6842

(6) Hatem, Samar; A Trial of Lidocaine Patch for Lower Limb Amputation Pain (Trial ongoing since 2016); Brugmann University Hospital

https://clinicaltrials.gov/ct2/show/study/NCT02696720?view=results

(7) Krumova EK1, Zeller M, Westermann A, Maier C. Lidocaine patch (5%) produces a selective, but incomplete block of Aδ and C fibers. Pain. 2012 Feb;153(2):273-80.

doi: 10.1016/j.pain.2011.08.020.

https://www.ncbi.nlm.nih.gov/pubmed/21995882

(8) Devers A, Galer BS. Topical lidocaine patch relieves a variety of neuropathic pain conditions: an open-label study. Clin J Pain. 2000 Sep;16(3):205-8.

https://www.ncbi.nlm.nih.gov/pubmed/11014393

(9) Many Other Lidocaine Patch/Pain Studies Can Be Found Here:

http://www.druglib.com/druginfo/lidoderm/abstracts/

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Successful Treatment of Primary Erythromelalgia with Ziconotide (Prialt)

Dear Pain Matters blog readers,

Here is an interesting case:

Primary Erythromelalgia Treated with Intrathecal Ziconotide:

A 31-year old woman suffered from primary erythromelalgia for most of her life.  Symptoms included:

  • Painful reddish skin and swelling in both feet and lower legs;
  • Loss of vision in right eye and severely impaired vision in left eye (due to bilateral congenital glaucoma, exophthalmos/abnormally protruding eyeballs and megalocornea);
  • Constant erythema and excessively warm lower legs;
  • Severe pain including:
    • Intense burning throughout both the lower legs;
    • Allodynia near the perimalleolar regions in both ankles; and
    • Hyperalgesia in bilateral gastrocnemius and instep (arched part of feet).

Physical examination confirmed warmer skin temperatures in the lower legs, very strong burning pain (10/10, when lying very still) and swollen ankles.  The skin on her feet was thickened, red and ulcerated, due to her habit of immersing her feet in cold water as often as possible (as part of self-medication).  Refer to (a) in first photo.  

March 2010 –

After trying ‘almost everything’, a decision was made to trial and implant an intrathecal pump drug delivery system in March 2010.

A low titration schedule from 0.3 mcg/die to 1.2 mcg/die of ziconotide was commenced.  This resulted in complete resolution of both allodynia and hyperalgesia.

Dosage was increased to 1.8 mcg/die.

It is noteworthy that the severe swelling and oedema in both lower legs and feet was significantly improved after 1 week of ziconotide treatment.  Refer to (b) in first photo.

CRIM2015-592170.001.jpgSource:   Russo et al, 2015

April 2013 (3 Years Later) –

In April 2013, the patient presented 4 days late for pump recharging.  This delay resulted in both legs and feet being swollen with burning pain.  Refer to (a) in below photo.  

Following (4-day-delayed) refill, her legs and feet were no longer swollen 2 days later, and there was nil burning pain 1 week later.  Refer to (b) in below photo.  

CRIM2015-592170.002.jpgSource: Russo et al, 2015

Summary:

The woman no longer had to immerse her feet in cold water resulting in improved skin appearance.  She was able to rest in a bed now (instead of staying up in a chair for months).  Overall, ongoing intrathecal ziconotide treatment offered an improved quality of life for the patient.

Long-term use of intrathecal ziconotide does not lead to addiction or tolerance.

Mechanisms:

Ziconotide exerts its analgesic effects by potently and selectively blocking neuronal N-type voltage-sensitive calcium channels at the presynaptic level, hence inhibiting neurotransmitter release.

Conclusion:

It is promising to see that severe pain including burning pain, hyperalgesia and allodynia, as well as swelling, redness and excessive warmth of lower legs and feet in patients with primary erythromelalgia may be managed by intrathecal ziconotide treatment in some cases.

Sabina Walker

“Sedare dolorem divinum opus est”
“It is divine to alleviate pain”

Galen, 130-200 C.E.

REFERENCE:

Russo R, Caroleo MC, Cione E, Perri M, Paparo MT, Russo A.

Dual Effect of Ziconotide in Primary Erythromelalgia.

Case Reports in Medicine (2015); Volume 2015, Article ID 592170, 4 pages.

doi:10.1155/2015/592170

https://www.hindawi.com/journals/crim/2015/592170/