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Transdermal Iontophoresis on Gerhardt-Mitchell's Disease of Joints - A rear case report
Corresponding Author: Mallikarjunaiah H.S., Mangalore, Mobile: +919886309123, E-mail: mallu.neuro.physio@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Thieme Medical and Scientific Publishers Private Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Gerhardt-Mitchell's disease which is also named as Erythromelalgia is an unusual neurovascular pain syndrome which features with group of three characteristics i.e., raise in temperature, red color pigmentation of skin and pain with a quality of burning. All three characteristics are most importantly seen in the extremities. Erythromelalgia may occur either as a primary or secondary disorder. Clinical presentation of primary erythromelalgia is linked with severe burning pain, pronounced erythemaof the skin, swelling and increased skin temperature, specifically of the feet. We present the case of a patient, 12 years old girl with primary erythromelalgia who came to our physiotherapy department with features of repeated redness, burning pain, increased warmness of the skin on anterior aspect of right foot. Computer Assisted Capillary Microscopy demonstrated reduced capillary density and capillary perfusion. Another observatory test was done by elevating patient's right leg noting the reversal in skin color from red to pale. Her detailed evaluation was carried out and physiotherapy treatment was started.
Introduction
Primary erythromelalgia is a rare condition that's characterized by erythema, an increased skin temperature and burning pain in the extremities. Erythromelalgia is a merging of three Greek words: erythros means redness, melos means extremities andalgos means pain.1 Its occurrence rate ranges from 0.36 to 1.1 per 100,000 persons.2 Many authors use these words synonymously Erythromelalgia, erythralgia and erythermalgia, while some of them differentiate between them depending on their underlined disorders.3 Treating a case of PE is supremely challenging especially for its feature of pain. There are various kinds of treatment routes given for erythromelalgia. Some listed are - oral route are neuroleptic drugs and vasodilator, certain drugs throughintravenous injections, some are intrusive such as by blocking Sympathetic ganglion and epidural route which are proved to be successful.1 Since many being invasive procedures we treated a case of 12 year old girl diagnosed with primary erythromelalgia by Iontophores is with transdermal administration of diclofenac.
Case Report
A 12-year old girl with the height of 126.8cms and weight of 26kgs came to physiotherapy department with marked redness, severe pain of right foot. Severe pain resulted in difficulty to walk. On observation we could find presence of marked redness, mild swelling and difficulty to bear weight on her right leg. At the age of 11 years she started to experience with features like warmness and reddish discoloration of skin on right foot. Hence she complained of past history of pain, pain experience was assessed for past i.e., age 11 and present i.e., age 12. Pain was assessed with Visual Analogue Scale (VAS) and depending on certain factors as mentioned in table below.
| PAIN ASSESSMENT | |
|---|---|
| At Age 11 | At Age 12 |
 |
 |
| Onset - Sudden | Onset - Sudden |
| Precipitating factor - Exposure to heat | Precipitating factor - Exposure to heat, prolonged weight bearing on right foot and walking |
| Quality of pain - Burning | Quality of pain - Burning |
| Relieving factor - Immersion of foot in cold water | Relieving factor - Immersion of foot in cold water |
| Site of pain - Right foot | Site of pain - Right foot |
| Temporal variation - Afternoon | Temporal variation - approximately around 11am to 5pm |
This suggested that pain intensity was increased from 4 to 8 on VAS in a pan of one year. On palpation we could find warmness of skin with moderate tenderness with grade 2 on anterior aspect of right foot over metatarsals.
On examination we assessed for Range of Motion (ROM), Muscle strength and Gait.
| Range Of Motion (ROM) using Standard Universal Goniometer | ||
|---|---|---|
| Right sideLeft side | ||
| Plantar flexion | 0–30° | 0–50° |
| Dorsiflexion | 0–15° | 0–20° |
| Inversion | 0–20° | 0–35° |
| Eversion | 0–15° | 0–25° |
| Muscle strength according to Daniel and Worthingham’s Grading | ||
|---|---|---|
| Right side | Left side | |
| Plantar flexors | Poor (+) | Normal (N) |
| Dorsiflexors | Poor (+) | Normal (N) |
| Invertors | Poor (+) | Normal (N) |
| Evertors | Poor (+) | Normal (N) |
On gait examination, type of gait was categorized to antalgic gait, for a reason being pain which limits the complete pattern of gait cycle. Pain can be a primary reason for decreased ROM, poor strength of muscles, variations in gait pattern. No abnormalities were seen on sensory system examination.
Computer Assisted Capillary Microscopy demonstrated reduced capillary density and capillary perfusion. Special test performed by us revealed reversal in skin color from red to pale on raising patient's right leg.
- Before
Treatment was started with Iontophoresis, transdermal administration of diclofenac on day 1 of her visit continued for 4days a week for 4 months at clinic. Besides this, dipping of her right foot in cold water was advised to be continued at home.
- After
Discussion
Erythromelalgia is known for being uncommon disorder yet late confirmation shows that it is presumably more typical and there is a wide range of side effect that encounters from minor pain to fearsome conditions that can involve arms or legs.3 Erythromelalgia is also called as Erythermalgia, Gerhardt Disease, Mitchell Disease, Weir-Mitchell Disease, Gerhardt-Mitchell's disease.4 Symptoms of this disease are aggravated by raised body temperature. They can begin subsequent to working out, by covering hands or feet with mitten, not withstanding devouring liquor or piquant foods.5 Inflammation, suppurative lesions of skin, death of localized living cells of involved limb is mostly seen. A subject had close lethal subnormal body temperature identified with frequent procedure that was applied to reduce the clinical manifestations seen because of Gerhardt-Mitchell's disease.6 Mark D. P. Davis studied to examine repeated incidence and nature of variations seen with vessel structure and nerve involvement seen in subjects with Erythromelalgia. Author revealed presence of pathology related to peripheral nerves is much greater, by side erythematic and raised skin temperature of localized area associated with intensified rush of blood in blood vessels.7 The intrusive treatments for Gerhardt-Mitchell's disease are related to insertion of anesthesia into lumbar spine a space between spinal cord and dura mater that inhibits the perception of pain sensation, nerve block, infusion of anesthesia close to the proximity of plexus brachialis, a device that delivers pulsed electrical signals to control chronic pain. At certain instances if manifestations does not diminish further nitropress, lignocaine, is given intravenously for lowering the levels of blood flow through vessels that cause erythema and to attenuate with other manifestations of Gerhardt-Mitchell's disease.1 All these procedures being invasive, a present case report assessed if transdermal application of diclofenac through Iontophoresis was applied in patients diagnosed with Gerhardt-Mitchell's disease, Iontophoresis would act as amanagement in a broader spectrum for clinical manifestations related to this condition.
Conclusion
A rear condition with Gerhardt-Mitchell's disease signified a better improvement with transdermal Iontophores is by delivering diclofenac ions through the superficial layer of skin into the tissue. Further to this we saw a vast diminishing of clinical manifestations associated with this disease i.e. is reduction in pain, redness and skin returning to normal temperature. This led to improving ROM, muscle strength and gait. Subjective analysis of VAS which was again assessed post to the intervention revealed to be 2 on analogue scale. Hence, further randomized control trial in larger number population is required for analysis of better efficacy.
References
- Sympathetic Block for Treating Primary Erythromelalgia. The Korean Journal of Pain. 2010;23((1)):55-59.
- [Google Scholar]
- Erythromelelgia? A Clinical Study of People Who Experience Red, Hot, Painful Feet in the Community. International Journal of Vascular Medicine 2013 April Available from:
- [Publisher] [Google Scholar]
- Low. Erythromelalgia: Vasculopathy and Neuropathy, or Both? Archives of Dermatology. 2003;139:1337-1343.
- [Google Scholar]