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 Post subject: Skin Complications in RSD
 Post Posted: Wed Mar 28, 2012 9:28 am 
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Skin Complications in RSD

Prof dr RJA Goris
Department of Surgery
University Medical Center Nijmegen
Nijmegen 6500 HB, The Netherlands


One of the complications that may occur in RSD of long standing is the appearance of
various skin problems. These problems do occur in some 5% of patients with long-standing RSD, and some may prove very difficult to heal. In this brief overview, I’ll discuss the most frequently occuring skin problems.

Dark discolouration of the skin

Initially, I thought this was due to excessive production of menin (skin pigment). But later it became clear that this dark skin actually consists of a thick outer layer of
epidermis, which may peel on occasion.

Image

Pic 1
Fig 1.
Example of severe late RSD with skin discolouration, chronic edema (swelling),
problems with skin and nail care, bruisable skin and some ulceration.


The discoloration occurs as a consequence of disuse of the limb (the outer layers of the skin do not wear off), and/or due to extreme hypersensitivity of the limb, impairing proper skin care. This discoloration is harmless and does not require special treatment. Washing, scrubbing, or eventually a cream with salicylic acid may solve the problem.

Abnormal nail growth

Most RSD patients may notice that the nails of the affected extremity may grow faster or slower, and may become harder and brittle.

Image


The nails may show a more pronounced curvature, in the axis of the finger and/or in a transverse direction (above). Technically, physicians refer to this as “hour-glass” nails. Cutting these hard nails in the presence of hyperalgesia may prove to be an ordeal. In the foot, especially the nail of the big toe, this
bending of the nail may cause an “ingrown toe nail.” This may require minor surgery, which is always tricky in a limb with RSD. In mild cases I suggest taking a flat
or triangular file and progressively thinning the middle area of the nail, so that it’s “back”is weakened and the pressure is taken off its sides. Evidently, this filing has
to be repeated regularly.

Thin, brittle skin

As a result of tissue atrophy, the skin may become very thin, tight, brittle, and easily bruised (Fig.2). The skin may also take on the appearance of eczema.

Image

Fig 2. (scan 1.4)
Example of thin, brittle, eczematous skin.

Skin ulceration

In worse cases, the skin may break down locally, resulting in slow-healing ulcers next to spots where new ulcers appear (Fig 3,4).

Image

Image

Fig 3 (top) and 4 (above)
Examples of a extensive ulceration of the skin.

Lymphedema

In extreme cases, a persistent severe swelling of the limb may result, possibly due to blockage of the lymphatics (Fig 5). In these cases, deep venous thrombosis has to be excluded. Because compression dressings may cause excruciating pain, they are not a treatment option. The swelling may reside partially with these dressings, but almost invariably recurs after stopping that particular form of treatment.

Image

Fig 5.
Example of case with severe lymphedema, skin discolouration and ulceration of the leg and foot (the bigtoe is just visible). There also is an extreme equinus position of the ankle joint. This exceptionnal patient finally developped severe infections in the
foot, finally requiring amputation.


In cases with the more severe skin changes (numbers 3to 5), I would suggest comparing the skin temperature with the healthy side. This can be done with an infrared
ear-thermometer. If the skin is substantially colder, measures should be taken to improve the blood circulation to the skin. We usually start with peripheral vasodilator drugs (verapamil, ketanserin etc, in fairly high doses if necessary and possible). If this does not
work or results in too many side effects, a sympathetic block may be considered. In the worst cases, we would admit the patient for treatment with an axillary catheter (upper extremity), or an epidural catheter (lower extremity).
Besides providing for optimal blood circulation in the skin, appropriate treatment of the RSD is mandatory. We therefore use an extensive protocol, including antioxydants. Also a protective, padded, well-aired splint may decrease the number of new skin ulcers.
Specific treatment for the skin changes caused by RSD by dermatologic methods, in my experience, has given little benefit; however, various skin creams may have additional therapeutic value.


Last edited by sharon on Wed Mar 28, 2012 10:31 am, edited 1 time in total.

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 Post subject: Skin Complications in RSD
 Post Posted: Wed Mar 28, 2012 10:26 am 
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Other Pictures of RSD

Image

Pic 1
Demonstrates brawny edema. Reddened thickened skin. Increased nail growth of the great toe. Deep ulcerated lesion on the top of the foot. Stage I of RSD.


Image

Pic 2
Atrophic reddened skin. Shiny skin that later desquamated. Stage III of RSD


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Pic 3
Striking example of livedo reticularis in Stage III of RSD patient.


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Pic 4
Example of atrophic skin with deep ulcer on the top of the right foot. Atrophic skin, loss of hair


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Pic 5
Example of early lesions that become ulcerated in latter stages. Stage I of RSD


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Pic 6
Very severe bilateral RSD stage II. Severe brawny edema, ulcerations, thickened curly hair


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Pic 7
Example of Gardner-Diamond Syndrome. Spontaneous bruises with central clearing of the left knee region.


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Pic 8
Commonly seen small punctate skin lesions that will ulcerate. Stage III of RSD


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Pic 9
Ligature signs, bilaterally below the knees. Nothing had been placed on the legs. Stage III of RSD


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Pic 10
Atrophic skin of stage III patient. Combination of loss of hair and increased thickness of hair



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Pic 11
Example of deep ulcer stage III.


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Pic 12
Example of Gardner-Diamond Syndrome.


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Pic 13
Blisters and livedo reticularis in Stage III of RSD.


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Pic 14
Severely infected and swollen foot gram negative infection with greenish pigment. A pseudomonas infection. Stage III of RSD.


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Pic 15
Ligature sign of right leg. Edema stops in and abrupt manner. Stage II of RSD


Image

Pic 16
Anchoring fibril deficiency. The patient sheds all of the skin from her arms and upper body. Stage III of RSD.


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 Post subject: RSD Rash
 Post Posted: Wed Mar 28, 2012 10:29 am 
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RSD RASH

If your doctor has ruled out side effects or adverse reactions to medications, you might be experiencing the RSD Rash. This is an immune system response that is very common in Stages 1 and 2 of RSD. It resembles Chicken Pox. The way to tell the difference between the RSD Rash and Chicken Pox/Shingles is that the RSD Rash has blood filled blisters whereas the Chicken Pox/Shingles has fluid filled blisters. It does itch and it can burn but does not always burn unless you break the blisters open. Although some people have reported that they also feel burning along with the itching. The rash may also appear as solid raised bumps.

Also, please be aware that since this is an immune system response, the rash can appear anywhere on your body and not where the RSD happens to be. Please do not think that the RSD is spreading to the area where the rash appears -- there is no connection.
There are prescription topical medications that you can ask your doctor to prescribe to help with the itching or you can use over the counter antihistamines if your doctor says it is OK - please check with him/her first before trying these.

You can also use some home remedies such as witch hazel or Milk of Magnesia dried to a paste. To dry Milk of Magnesia to a paste -- just put it on a paper plate and let it dry out a bit. Put either the witch hazel or the MOM on the affected area to help stop the itching.

Another home remedy that helps with the itching is Epsom Salt baths. Epsom salt baths also help with RSD pain. Epsom Salt (Magnesium Sulfate U.S.P) is a 100% Natural Mineral long been considered a trusted natural remedy for everything from the winter blues to a laxative.

First, Please do not try this before asking your doctor if this is OK for you to do - ESPECIALLY IF YOU HAVE DIABETES! Also do not use if you have any open infected wounds. Epsom salts are great for non infected wounds. Soak in the tub with warm (85-95 degree) water with Epsom Salts. This will help improve circulation which will reduce inflammation, pain, and itching. It will also very quickly bring warmth to your limbs if you suffer from "cold" limbs.

Some may feel uncomfortable for the first few minutes when first getting in the warm water -- this is common. But if you continue to feel uncomfortable -- this is not and you should discontinue.

This is why it works: While you are soaking, the Epsom Salts removes the poisonous and irritative chemicals from the involved extremity through the skin. The Epsom salts acts as a calcium channel blocker which helps reduce the pain, inflammation, edema and breakdown of tissues.

Another great home remedy is Banana Boat's Sooth-A-Caine which can be found at your local grocery or drug store. It is a non greasy spray gel that contains lidocaine and menthol. Many RSDers have reported that they get relief from not only the burning pain but also from the crushing type pain as well as helping with the rash. If you try this product and get relief from it, you might want to ask your doctor about Lidoderm 5% Lidocaine patches which require a prescription but seem to help people that have had success with the Sooth-A-Caine for their RSD pain.


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 Post subject: Re: Skin Complications in RSD
 Post Posted: Wed Mar 28, 2012 10:44 am 
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Wow Sharon,

This is brilliant. Thank you so much for putting this together, it will help a lot of people.

Lots of love
Sian

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 Post subject: Re: Skin Complications in RSD
 Post Posted: Wed Mar 28, 2012 12:35 pm 
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Thanks Sian. I've had this for years but couldnt work out how to get it off a PDF file. The first bit is from the RSDA clinical guideliness. I worked out how to copy and paste the words, but it was the pictures that I could work out how to add, then this morning I had a light bulb moment lol...up load it to photobucket! why I have never thought about it before I never know!!! but I have done it know, so I can know add lots more lol

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 Post subject: Re: Skin Complications in RSD
 Post Posted: Wed Mar 28, 2012 3:01 pm 
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Thanks very much Sharon for your hard work, I will study the pictures again later to see if any of them match the type of rash I have,

Susan
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 Post subject: Re: Skin Complications in RSD
 Post Posted: Wed Mar 28, 2012 7:14 pm 
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Nice one Sharon, I recall you posting it elsewhere, then I lost it. Great to have it back!!!

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 Post subject: Re: Skin Complications in RSD
 Post Posted: Wed Mar 28, 2012 8:26 pm 
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My what a busy little bee you have been Sharon.......Thank you so much for sharing all your hard work with us..........It's strange as I had this rash for a while on my face infact it was like a big red spot on my cheak.......I saw the skin specialist and he said it was nothing to worry about......Nothing to worry about :rofl: :rofl: having a huge red spot on my cheak and it would take weeks before it went........it came back again and then it came on the side of my nose and above my lip I tried everything to get rid of it but nothing worked.....the skin on my face was also very dry........Guess what happened I came of the anti depressents and with in days my skin started to heal the huge red spot is almost gone as to is the dry skin on my face.........I must admit I was beginning to get a little worried ( bit to old to be having spots on my skin imao :rofl: ). Maybe it was the medicine maybe it wasn't but what ever it was it's almost gone now that I have stopped taking the tablets.........take care love Lynne xxxxx

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 Post subject: Re: Skin Complications in RSD
 Post Posted: Mon Jul 23, 2012 10:43 am 
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This is a fantastic bit of research well done I am sure many people will find it useful. I have also heard that having a scs can reduce swelling and some sufferers actual have little skin discolouration after time. I still have such burning skin that I have to scratch it to try and dig it out. This of course causes more pain but just dont know what to do when this happens. Thanks for the info again.


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