dob7021

8/10/2019 DOB7021

1/4

Scalp Dysesthesia

Diane Hoss, MD; Samantha Segal, MD

Background: Cutaneous dysesthesia syndrome is a dis-order characterized by chronic cutaneous symptoms with-outobjective findings. Patientscomplain of burning, sting-ing, or itching, which is often triggered or exacerbatedby psychological or physical stress. These symptoms maybe manifestations of an underlying psychiatric disorderor may represent a type of chronic pain syndrome.

Observations: Elevenwomenpresentedwithchronic se-vere pain and/or pruritus of the scalp only without objec-tivephysical findings, a condition wetermscalpdysesthe-sia. Five women described pain, stinging, or burning only;4 women complained of pain and pruritus; and 2 women

reported pruritus only. Thepatients ranged in agefrom 36to70years.Thedurationofsymptomsrangedfrom9months

to 7 years. Five women had physician-diagnosed psychi-atricdisorders,includingdysthymicdisorder,generalizedanxiety,andsomatization.Sevenwomenreportedthatstresstriggers or exacerbates their symptoms. Eight women ex-perienced improvement or complete resolution of symp-toms with treatment withlow-dosedoxepin hydrochlorideoramitriptylinehydrochloride.Onepatientrespondedcom-pletely to treatment with sertralineand hydroxyzinehydro-chloride but then experienced a relapse.

Conclusions:We describe 11 patients with a new syn-dromethat we term scalp dysesthesia.Of11 patients,9 ben-efited from treatment with low doses of antidepressants.

Arch Dermatol. 1998;134:327-330

THE CHRONICpainsyndromesinclude the burning mouthsyndrome(synonyms:gloss-odynia, stomatodynia, oraldysesthesia, glossopyrosis,

and stomatopyrosis), vulvodynia, scroto-dynia,andatypicalfacialpain(synonym,oro-facial dysesthesia). Patients with 1 of thesesyndromesreportlocalizedcutaneousormu-cosaldebilitatingpainorburning,sometimes

withoutabnormalphysicalfindings.Wede-scribe 11 women with chronic distressingscalp symptoms,a conditionwetermscalpdysesthesia.

REPORT OF CASES

The characteristics of the 11 women withscalpdysesthesiaarepresentedintheTable.

COMMENT

In 1981,Cotterill1 described 28patientswithdermatologic non-disease. These pa-

tients reported significant facial, scalp, andgenital burning and discomfort or itchingoften associated with a disturbed body im-age (body dysmorphic disorder). Koblen-zer andBostrom2 coined the term chroniccutaneous dysesthesia syndrome to referto patients whose primary cutaneouscom-plaint is dysesthesia. Dysesthesia can be de-fined as a disagreeable sensation presentwith ordinary stimuli.3 Chronic cutane-ous dysesthesia is a separate clinical entity

from body dysmorphic disorder or a cir-cumscribed delusion, such as delusions ofparasitosis.2 Examples of chronic cutane-ousdysesthesia includethe burning mouthsyndrome, vulvodynia, scrotodynia, andatypical facial pain.

Whenconfrontedwitha patient com-plainingoflocalizedpain,onemustconsiderpossible underlying localized organic dis-ease, systemic organic disease, or psycho-

logicaldisease.Inthecaseofburningmouthsyndrome, the physician must rule out lo-cal disease(geographictongue,candidiasis,or contact stomatitis),systemicdisease(dia-betes,xerostomiadue to Sjogren syndromeor medication use,or vitamindeficiencies),or psychologicaldisease.4 Similarconsider-ation must be given to women with vulvo-dynia3 andpatientswithorofacialdysestheia.5

Cutaneousdisease waspresent in only1 of our patients. Patient 6 had biopsy-provenprurigonodularisof thescalp.Theselesions were caused by constant picking ofa pruriticandburning scalpina patient with

known atopic dermatitis. Herprurigo nodu-laris lesions, which were present for5 years,completely disappeared when her scalpsymptoms resolved. None of our patientsexhibited signs of psoriasis or seborrheicdermatitis that might have caused theirsymptoms.

We also considered whether alope-ciacouldhave causedor contributed to thescalp dysesthesia in our patients. Of our11 patients, 7 (2 premenopausal and 5

OBSERVATION

From the Department ofDermatology, University ofConnecticut Health Center,Farmington.

ARCH DERMATOL/ VOL 134, MAR 1998327

1998 American Medical Association. All rights reserved.

wnloaded From: http://archderm.jamanetwork.com/ on 10/09/2014

8/10/2019 DOB7021

2/4

Characteristics of Women With Scalp Dysesthesia*

PatientNo./

Age, yComplaint/Duration, y

ScalpConditions

MedicalHistory

AssociatedLife Events

PsychiatricDisorders

Patient-IdentifiedExacerbatingFactors Type of Treatment Outcome

1/35 Burning, initialtransientpruritus/2

Telogeneffluvium

Premeno-pausal

Marital stress,new job

Dysthymic disorder(P)

Worsens withstress

Doxepin hydrochloride,50 mg/d

CR, then recurred 3times whendoxepin usestopped; CRwhen restarteduse

2/66 Pain, burning,stinging/7

Mild AGA PUD,arthritis,postmeno-pausalusing ERT

None Hypochondriasis,anxiety disorder(PCP)

Denies Doxepin hydrochloride,30 mg/d; amitriptylinehydrochloride, 10 mgat bedtime

Improvedsymptoms; CRinitially with mildrecurrence

3/70 Tightness/4(like ahelmet onmy head)worsened/1

Mild AGA Familyhistory ofdepres-sion,postmeno-pausalwith noERT

Retired for 2 y Refuses psychiatricevaluation

Im a veryintense person


Markedimprovement

4/36 Pain withcombing

and cold,formication,tightfeeling/3

Mild AGA Premeno-pausal

Immigration N one Worsens withstress

Doxepin hydrochloride,50 mg/d; hydoxyzine

hydrochloride, 50mg/d

Improvedsymptoms, NR

5/40 Pain andburning/2

Mild AGA Premeno-pausal

Marital stress Anxiety disorder(PCP)

Worsens withstress, anxiety

Alprazolam, 0.25 mg/d

Doxepin hydrochloride,50 mg at bedtime;lorazepam, 1 mg atbedtime

Mild relief ofsymptoms;(alprazolan)

Noncompliant(doxepin);mild relief ofsymptoms(lorazepam)

6/58 Constantsoreness,occasionalburning/9 mo

Mild AGA Postmeno-pausalusing ERT

. . . None Worsens withwind, shower,and grooming,not worsenedby stress,

onsetassociated withfree-floatinganxiety

Amitriptylinehydrochloride, 20 mgat bedtime

90% resolution ofsymptoms 3weeks after takingmedication; CRafter 10 months

using medication;symptoms recurif amitriptylineuse isdiscontinued

7/61 Pruritus/5;burning/2

Prurigonodularis

Atopicdermatitis,postmeno-pausalusing ERT

Stress Generalized anxietydisorder (P),acute panicdisorder (P),dysthymicdisorder withobsessive andsomaticcomponents (P)

Worsens withstress

Intralesionaltriamcinolone;

Acetonide hydroxyzinehydrochloride, 50 mg;topical doxepin;

Diprolene gel,elocon lotion, 1%hydrocortisone foamwith 1% pramoxine,temovate cream;


NR

NR

NR

NR

Combination ofsertraline, 50 mg/d;hydroxyzinehydrochloride, 50mg/d; intralesionaltriamcinoloneacetonide, 10 mg/mL;and psychiatricconsultation

CR for 1 year, thenexperienced arelapse usingtherapy

(continued)




8/10/2019 DOB7021

3/4

postmenopausal)had mild androgenetic alopecia (AGA).In 1960, Sulzberger et al6 reported that women with dif-

fuse alopecia complained of associated scalp symp-toms, including spotty tenderness, tingling, crawling,itching, burning and uncomfortable awareness of thescalp. Mild AGA is common in women. Venning andDawber7 noted mild AGA in 220 (87%) of 254 premeno-pausal women seen in a dermatology clinic for reasonsother than hair loss. Thus, our patients do not have anincreased incidence of AGA compared with the generalpopulation. It is unlikely that mild AGA is the sole causeof the scalp symptoms in these 7 women. Even if mildAGA is the cause, control of scalp symptoms can beachieved without changing the clinical finding of AGA.

Patient1haddocumentedtelogeneffluviumon2sepa-rate occasions.No causewas determinedfor thetelogenef-

fluvium.Theresultsofacompletebloodcellcount,thyroidfunctiontests, andironstudieswereallnormal.Treatmentof her scalp burning with doxepin hydrochloride resultedincessationofburningand decreaseddailyhair loss onbothoccasions.Arecentreviewoftelogeneffluviumdoesnot men-tion scalpburningassociated with increaseddailyhair loss.8

Temporal arteritis and tension headaches are under-lying medical conditions withsymptoms that may includescalp pain or tightness. Features that militate against a di-agnosis of temporal arteritis in our patients are the diffusedistributionofthescalppainandthepresenceofnormaleryth-

rocyte sedimentation rates in those patients tested. Whenqueried, allpatientsstatedthat their pain didnot resemble

aheadache.The2womenwhoreportedscalpprurituswith-outpainhadnegativeornormalresultsofalaboratoryworkupforpruritus(completebloodcell count,liver function tests,and measurement of levels of blood urea nitrogen, creati-nine, glucose, and thyroid stimulating hormone).

A psychiatric cause or overlay has been reported inpatients with chronic pain syndromes or cutaneousdysesthesias.1,2,9-12 Infact,chronicpain hasbeenreferredtoasa depressiveequivalent.9 Manyofthechronicpainsyn-dromeswereinitially thoughtto represent a psychiatric dis-order only. However, one must be cautious when review-ingdata describinga personalityprofile or a psychiatricdis-order associated withany chronic condition, particularly apainfulone.3,13 Isa psychiatric disturbance (ie,depression)

thecauseofchronicpainordoesexperiencingchronicpainresultin symptoms ofdepression? A subsetof chronic painsufferers probably dohavean underlying psychiatric illnesscausingtheirsymptoms.However,intheexperienceofBow-ers,13 most of the cutaneous/mucosal pain syndromes arenotcausedby psychological pathology.Continuedresearchinto thechronicpainsyndromes nowsuggests that they mayrepresenta neurologic dysfunction thatin some casesis as-sociated with a secondary psychiatric component.

It is interesting that 5 of our patients had 1 or morephysician-diagnosedpsychiatric disorders.Dysthymicdis-

Characteristics of Women With Scalp Dysesthesia*(cont)

PatientNo./

Age, yComplaint/Duration, y

ScalpConditions

MedicalHistory

AssociatedLife Events

PsychiatricDisorders

Patient-IdentifiedExacerbatingFactors Type of Treatment Outcome

8/59 Pain andpruritus/4

Mild AGA Postmeno-pausalusing ERT

Mothers illness4 years ago;mothersdeath 1 yearago; elderlywidowedfather

None Im a nervousperson, Ithought it wasdue to stress

Amitriptylinehydrochloride, 20 mg/d

CR after 3 monthsof treatment;symptomsrecur iftreatmentdiscontinued

9/49 Pruritus/5 None Premeno-pausal

Marital stress Generalized anxietydisorder,somaticizationdisorder (P)

Im a very highstrung person,worsens withmenses

1% Hydrocortisone foamwith 1% pramoxine,fluocinolone solution,0.01%, diprolene lotion,triamcinolone acetonidelotion, 0.1%, eloconlotion; topical doxepin;doxepin hydrochloride,10-100 mg/d;alprazolam, 0.25 mg/d;amitriptylinehydrochloride, 50 mg/d;sertraline, 75 mg/d

NR

10/52 Pruritus/3 None Postmeno-pausalusing ERT

Fathers death;family stress

None Worse withstress,sweating,warmth,wearing hats

Topical steroidDoxepin hydrochloride,

30 mg/dNortriptylinehydrochloride, 25 mg atbedtime

NR40%

improvementUnknown

11/67 Tenderness,burning, andpruritus/1

Mild AGA Postmeno-pausalwithoutERT

. . . . . . Worse in morningand combing orwashing hair

Doxepin hydrochloride, 20mg at bedtime

CR (tendernessand burning) in6 months; CR(pruritus) in 10months

*P indicates diagnosed by a psychiatrist or psychologist; CR, complete resolution of symptoms; AGA, androgenetic alopecia; PUD, peptic ulcer disease; ERT, estrogenreplacement therapy; PCP, diagnosed by patients primary care physician; NR, no response; and ellipses, not applicable.




8/10/2019 DOB7021

4/4

order, a mood disturbance characterized by a chronicallydepressed mood, was present in 2 patients. Prior somati-zation was present in 3 patients. Generalized anxiety waspresent in 4 patients.Of these 5 patients,4 hadpsychiatricproblems that were present prior to theonset of scalp dys-esthesia. Of the 11 patients we describe herein, the symp-toms in 7 patients intensified with psychological stress.

A common denominator of many chronic pain syn-dromes is improvementor complete resolution withtreat-

ment with low-dose antidepressants.13

Three possiblemechanisms have been proposed14,15: first, antidepres-sant use may relieve depression associated with or causedby chronic pain and thus improve symptoms; second, thetricyclic antidepressants may have analgesic properties;and/or third, depression and pain may sharea similar un-derlying biochemical mechanism.

Several placebo-controlled studies have documentedthe efficacy of low-doseantidepressantsfor treating chronicpain. Postherpetic neuralgia respondsto treatment with ami-triptyline hydrochloride as demonstrated in a double-blind, placebo-controlled, crossover study.16 There was nosignificant antidepressiveeffectwith thelowdosesused (me-dian dose, 75 mg). A 1992 placebo-controlled study17 com-

pared the efficacy of desipramine hydrochloride, amitrip-tyline, and fluoxetine hydrochloride for treating chronicpain in diabetic neuropathy. Desipramine and amitripty-line were equally effective and superior to placebo in bothdepressed and nondepressed patients with diabetic neu-ropathy. Fluoxetine hadno greater analgesiceffect than pla-cebo in nondepressed patients. Patients who were de-pressedbenefited fromfluoxetinetherapy.In a retrospectivereview, McKay18 reported that dysesthetic (essential) vul-vodynia responds to treatment with low-dose amitripty-line. Gabapentin, a newly released anticonvulsant medi-cation,hasbeen effective in treatingchronicpain syndromes(erythromelalgia19 and reflex sympathetic dystrophy20) inuncontrolled studies. In the future, this drug may prove

to be a useful adjunctive therapy for managing a variety ofchronic pain syndromes, including scalp dysesthesia.

Of the 11 patients, 9 experienced improvement orcomplete resolution of their scalp symptoms with low-dose antidepressant treatment. Patient 9 (with pruritusonly) was not responsive to numerous therapies includ-ing several antidepressants. Patient 5 was unavailable forfollow-up. Patient 7 responded to therapy for 1 year butthen hada relapse. Patients 1, 6, and8 reported that symp-toms recur if use of the medication is stopped. The posi-tive response to therapy supports our beliefthat scalp dys-esthesia represents a chronic pain syndrome or a subsetof the cutaneous dysesthesia syndrome.

It might be argued that patients with only scalp pru-

ritus may have a different conditionthan those complain-ing of scalp pain. We included those patients with onlypruritusfor severalreasons: first, severalpatientswithpainor burning reported coexisting pruritus or initial tran-sient pruritus; second, there appeared to be a spectrum ofcomplaints ranging from pain only, to pain and pruritus,to pruritus only; and third, the degree of interference withdaily life seemed similar in all patients regardless of theirspecific symptom. The sensations of both pain and itchare carried on the same unmyelinated (slow), afferent,group C nerve fibers. However, patients with only pruri-

tus were less responsive or unresponsive to therapy withlow-dose antidepressants.

CONCLUSIONS

Wedescribe11 women withscalp dysesthesia,a conditionthat we believe is a type of chronic cutaneous dysesthesia.These women experienced debilitating scalp pain and/orpruritus. We are not certain if our patients have pain sec-

ondary to underlyingpsychiatric conditions, suchas anxi-ety, dysthymicdisorder, andsomatization, or if these psy-chiatric problemsareunrelated or causedby thescalpdys-esthesia. More studies are needed to determine the causeofscalp dysesthesiaand defineanyrole psychiatricdiseasesmayplay in causing or enhancing thepain experienced bythesepatients. Further studies shouldalso formally evalu-atetheefficacy of treatingscalpdysesthesiawith low-doseantidepressants.

Accepted for publication August 3, 1997.We acknowledge Jean Vogel, MD, for performing psy-

chiatric evaluations of 2 of our patients and Peter Lynch,MD, for providing helpful suggestions regarding therapy with

low-dose antidepressants.Reprints: Diane Hoss, MD, University of Connecticut

Health Center, Dowling South, Suite 300, MC 6230, 263Farmington Ave, Farmington, CT 06030.

REFERENCES

1. Cotterill JA. Dermatological non-disease: a common and potentially fatal distur-bance of cutaneous body image. Br J Dermatol.1981;104:611-619.

2. Koblenzer CS, Bostrom P. Chronic cutaneous dysesthesia syndrome: a psy-chotic phenomenon or a depressive symptom? J Am Acad Dermatol. 1994;30:370-374.

3. McKayM. Vulvodynia,scrotodynia,and otherchronic dysesthesiasof the anogeni-talregion (includingpruritusani).In: BernhardJD,ed. Itch:Mechanisms and Man-agement of Pruritus.New York, NY: McGraw-Hill Book Co; 1994:161-183.

4. Huang W, Rothe MJ, Grant-Kels JM. The burning mouth syndrome.J Am Acad

Dermatol.1996;34:91-98.5. Aghabeigi B. The pathophysiology of pain.Br Dent J.1992;173:91-97.6. Sulzberger MB, Witten VH, Kopf AW. Diffuse alopecia in women.Arch Derma-

tol.1960;81:108-112.7. Venning VA, Dawber RPR. Patterned androgenic alopecia in women.J Am Acad

Dermatol.1988;18:1073-1077.8. HeadingtonJT. Telogen effluvium: new concepts and review. Arch Dermatol. 1993;

129:356-363.9. KoblenzerCS. Psychocutaneousdisease.In: MoschellaSL, Hurley HJ, eds. Der-

matology.Philadelphia, Pa: WB Saunders Co; 1992:2025-2041.10. Lynch PJ. Vulvodynia: a syndrome of unexplained vulvar pain, psychologic dis-

ability and sexual dysfunction.J Reprod Med. 1986;31:773-780.11. FeinmannC, Harris M, Cawley R. Psychogenic facial pain: presentationand treat-

ment.BMJ.1984;288:436-438.12. Hampf G, Vikkula J, Ylipaavalniemi P, Aalberg V. Psychiatric disorders in orofa-

cial dysaesthesia.Int J Oral Maxillofac Surg. 1987;16:402-407.13. Bowers KE.Cutaneous andmucosalpain syndromes.Med SurgDermatol. 1995;

2:129-132.14. Lee R, Spencer PSJ. Antidepressants and pain: a review of the pharmacological

datasupporting the useof certain tricyclicsin chronic pain.J Int Med Res. 1977;5(suppl 1):146-156.15. Feinmann C. Painreliefby antidepressants: possible modes of action.Pain. 1985;

23:1-8.16. Watson CP, Evans RJ, Reed K, Merskey H, Goldsmith L, Warsh J. Amitriptyline

versus placebo in postherpetic neuralgia.Neurology.1982;32:671-673.17. Max MB, Lynch SA, Muir J, Shoaf SE, Smoller B, Dubner R. Effects of desipra-

mine, amitriptyline and fluoxetine on pain in diabetic neuropathy.N Engl J Med.1992;326:1250-1256.

18. McKay M. Dysesthetic (essential) vulvodynia:treatment withamitriptyline.J Re-prod Med.1993;38:9-13.

19. McGraw T, Kosek P. Erythromelalgia pain managed with gabapentin.Anesthe-siology.1997;86:988-990.

20. Mellick GA, Mellick LB. Reflex sympathetic dystrophy treated with gabapentin.Arch Phys Med Rehabil.1997;78:98-105.



wnloaded From: http://archderm jamanetwork com/ on 10/09/2014

dob7021

Documents