Scalp Dysesthesia

OBSERVATION Scalp Dysesthesia

Diane Hoss, MD; Samantha Segal, MD

Background: Cutaneous dysesthesia syndrome is a dis- to 7 years. Five women had physician-diagnosed psychi- order characterized by chronic cutaneous symptoms with- atric disorders, including dysthymic disorder, generalized out objective findings. Patients complain of burning, sting- anxiety, and somatization. Seven women reported that stress ing, or itching, which is often triggered or exacerbated triggers or exacerbates their symptoms. Eight women ex- by psychological or physical stress. These symptoms may perienced improvement or complete resolution of symp- be manifestations of an underlying psychiatric disorder toms with treatment with low-dose doxepin hydrochloride or may represent a type of chronic pain syndrome. or amitriptyline hydrochloride. One patient responded completely to treatment with sertraline and hydroxyzine hydro- Observations: Eleven women presented with chronic se- chloride but then experienced a relapse. vere pain and/or pruritus of the scalp only without objective physical findings, a condition we term “scalp dysesthe- Conclusions: We describe 11 patients with a new syn- sia.” Five women described pain, stinging, or burning only; drome that we term scalp dysesthesia. Of 11 patients, 9 ben- 4 women complained of pain and pruritus; and 2 women efited from treatment with low doses of antidepressants. reported pruritus only. The patients ranged in age from 36 to70years.Thedurationofsymptomsrangedfrom9months Arch Dermatol. 1998;134:327-330

HE CHRONIC painsyndromes from body dysmorphic disorder or a cir- include the burning mouth cumscribed delusion, such as delusions of syndrome(synonyms:gloss- parasitosis.2 Examples of chronic cutane- odynia, stomatodynia, oral ous dysesthesia include the burning mouth dysesthesia, glossopyrosis, syndrome, vulvodynia, scrotodynia, and Tand stomatopyrosis), vulvodynia, scroto- atypical facial pain. dynia,andatypicalfacialpain(synonym,oro- When confronted with a patient com- facial dysesthesia). Patients with 1 of these plaining of localized pain, one must consider syndromesreportlocalizedcutaneousormu- possible underlying localized organic dis- cosaldebilitatingpainorburning,sometimes ease, systemic organic disease, or psycho- without abnormal physical findings. We de- logical disease. In the case of burning mouth scribe 11 women with chronic distressing syndrome, the physician must rule out lo- scalp symptoms, a condition we term “scalp cal disease (geographic tongue, candidiasis, dysesthesia.” or contact stomatitis), systemic disease (dia- betes, xerostomia due to Sjo¨gren syndrome REPORT OF CASES or medication use, or vitamin deficiencies), or psychological disease.4 Similar consider- The characteristics of the 11 women with ation must be given to women with vulvo- scalp dysesthesia are presented in the Table. dynia3 andpatientswithorofacialdysestheia.5 Cutaneous disease was present in only COMMENT 1 of our patients. Patient 6 had biopsy- proven prurigo nodularis of the scalp. These In 1981, Cotterill1 described 28 patients with lesions were caused by constant picking of “dermatologic non-disease.” These pa- a pruritic and burning scalp in a patient with tients reported significant facial, scalp, and known atopic dermatitis. Her prurigo nodu- genital burning and discomfort or itching laris lesions, which were present for 5 years, often associated with a disturbed body im- completely disappeared when her scalp age (body dysmorphic disorder). Koblen- symptoms resolved. None of our patients zer and Bostrom2 coined the term “chronic exhibited signs of psoriasis or seborrheic cutaneous dysesthesia syndrome” to refer dermatitis that might have caused their to patients whose primary cutaneous com- symptoms. From the Department of plaint is dysesthesia. Dysesthesia can be de- We also considered whether alope- Dermatology, University of fined as “a disagreeable sensation present cia could have caused or contributed to the Connecticut Health Center, with ordinary stimuli.”3 Chronic cutane- scalp dysesthesia in our patients. Of our Farmington. ous dysesthesia is a separate clinical entity 11 patients, 7 (2 premenopausal and 5

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Patient Patient-Identified No./ Complaint/ Scalp Medical Associated Psychiatric Exacerbating Age, y Duration, y Conditions History Life Events Disorders Factors Type of Treatment Outcome 1/35 Burning, initial Telogen Premeno- Marital stress, Dysthymic disorder “Worsens with Doxepin hydrochloride, CR, then recurred 3 transient effluvium pausal new job (P) stress” 50 mg/d times when pruritus/2 doxepin use stopped; CR when restarted use 2/66 Pain, burning, Mild AGA PUD, None Hypochondriasis, Denies Doxepin hydrochloride, Improved stinging/7 arthritis, anxiety disorder 30 mg/d; amitriptyline symptoms; CR postmeno- (PCP) hydrochloride, 10 mg initially with mild pausal at bedtime recurrence using ERT 3/70 Tightness/4 Mild AGA Family Retired for 2 y Refuses psychiatric “I’m a very Doxepin hydrochloride, Marked (“like a history of evaluation intense person” 50 mg/d improvement helmet on depres- my head”) sion, worsened/1 postmenopausal with no ERT 4/36 Pain with Mild AGA Premeno- Immigration None “Worsens with Doxepin hydrochloride, Improved combing pausal stress” 50 mg/d; hydoxyzine symptoms, NR and cold, hydrochloride, 50 formication, mg/d tight feeling/3 5/40 Pain and Mild AGA Premeno- Marital stress Anxiety disorder “Worsens with Alprazolam, 0.25 mg/d Mild relief of burning/2 pausal (PCP) stress, anxiety” symptoms; Doxepin hydrochloride, (alprazolan) 50 mg at bedtime; Noncompliant lorazepam, 1 mg at (doxepin); bedtime mild relief of symptoms (lorazepam) 6/58 Constant Mild AGA Postmeno- . . . None Worsens with Amitriptyline 90% resolution of soreness, pausal wind, shower, hydrochloride, 20 mg symptoms 3 occasional using ERT and grooming, at bedtime weeks after taking burning/ not worsened medication; CR 9mo by stress, after 10 months onset using medication; associated with symptoms recur “free-floating if amitriptyline anxiety” use is discontinued 7/61 Pruritus/5; Prurigo Atopic Stress Generalized anxiety “Worsens with Intralesional NR burning/2 nodularis dermatitis, disorder (P), stress” triamcinolone; postmeno- acute panic Acetonide hydroxyzine NR pausal disorder (P), hydrochloride, 50 mg; using ERT dysthymic topical doxepin; disorder with Diprolene gel, NR obsessive and elocon lotion, 1% somatic hydrocortisone foam components (P) with 1% pramoxine, temovate cream; Doxepin hydrochloride, NR 40 mg/d Combination of CR for 1 year, then sertraline, 50 mg/d; experienced a hydroxyzine relapse using hydrochloride, 50 therapy mg/d; intralesional triamcinolone acetonide, 10 mg/mL; and psychiatric consultation

(continued)

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Patient Patient-Identified No./ Complaint/ Scalp Medical Associated Psychiatric Exacerbating Age, y Duration, y Conditions History Life Events Disorders Factors Type of Treatment Outcome 8/59 Pain and Mild AGA Postmeno- Mother’s illness None “I’m a nervous Amitriptyline CR after 3 months pruritus/4 pausal 4 years ago; person,” “I hydrochloride, 20 mg/d of treatment; using ERT mother’s thought it was symptoms death 1 year due to stress” recur if ago; elderly treatment widowed discontinued father 9/49 Pruritus/5 None Premeno- Marital stress Generalized anxiety “I’m a very high 1% Hydrocortisone foam NR pausal disorder, strung person,” with 1% pramoxine, somaticization “worsens with fluocinolone solution, disorder (P) menses” 0.01%, diprolene lotion, triamcinolone acetonide lotion, 0.1%, elocon lotion; topical doxepin; doxepin hydrochloride, 10-100 mg/d; alprazolam, 0.25 mg/d; amitriptyline hydrochloride, 50 mg/d; sertraline, 75 mg/d 10/52 Pruritus/3 None Postmeno- Father’s death; None “Worse with Topical steroid NR pausal family stress stress, Doxepin hydrochloride, 40% using ERT sweating, 30 mg/d improvement warmth, Nortriptyline Unknown wearing hats” hydrochloride, 25 mg at bedtime 11/67 Tenderness, Mild AGA Postmeno- ...... Worse in morning Doxepin hydrochloride, 20 CR (tenderness burning, and pausal and combing or mg at bedtime and burning) in pruritus/1 without washing hair 6 months; CR ERT (pruritus) in 10 months

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

postmenopausal) had mild androgenetic alopecia (AGA). rocyte sedimentation rates in those patients tested. When In 1960, Sulzberger et al6 reported that women with “dif- queried, all patients stated that their pain did not resemble fuse alopecia” complained of associated scalp symp- a headache. The 2 women who reported scalp pruritus with- toms, including “spotty tenderness, tingling, crawling, outpainhadnegativeornormalresultsofalaboratoryworkup itching, burning and uncomfortable awareness of the for pruritus (complete blood cell count, liver function tests, scalp.” Mild AGA is common in women. Venning and and measurement of levels of blood urea nitrogen, creati- Dawber7 noted mild AGA in 220 (87%) of 254 premeno- nine, glucose, and thyroid stimulating hormone). pausal women seen in a dermatology clinic for reasons A psychiatric cause or overlay has been reported in other than hair loss. Thus, our patients do not have an patients with chronic pain syndromes or cutaneous increased incidence of AGA compared with the general dysesthesias.1,2,9-12 In fact, chronic pain has been referred to population. It is unlikely that mild AGA is the sole cause as a “depressive equivalent.”9 Many of the chronic pain syn- of the scalp symptoms in these 7 women. Even if mild dromes were initially thought to represent a psychiatric dis- AGA is the cause, control of scalp symptoms can be order only. However, one must be cautious when review- achieved without changing the clinical finding of AGA. ing data describing a personality profile or a psychiatric dis- Patient 1 had documented telogen effluvium on 2 sepa- order associated with any chronic condition, particularly a rate occasions. No cause was determined for the telogen ef- painful one.3,13 Is a psychiatric disturbance (ie, depression) fluvium. The results of a complete blood cell count, thyroid the cause of chronic pain or does experiencing chronic pain function tests, and iron studies were all normal. Treatment result in symptoms of depression? A subset of chronic pain of her scalp burning with doxepin hydrochloride resulted sufferers probably do have an underlying psychiatric illness in cessation of burning and decreased daily hair loss on both causing their symptoms. However, in the experience of Bow- occasions.Arecentreviewoftelogeneffluviumdoesnotmen- ers,13 “most of the cutaneous/mucosal pain syndromes are tion scalp burning associated with increased daily hair loss.8 not caused by psychological pathology.” Continued research Temporal arteritis and tension headaches are under- into the chronic pain syndromes now suggests that they may lying medical conditions with symptoms that may include represent a neurologic dysfunction that in some cases is as- scalp pain or tightness. Features that militate against a di- sociated with a secondary psychiatric component. agnosis of temporal arteritis in our patients are the diffuse It is interesting that 5 of our patients had 1 or more distributionofthescalppainandthepresenceofnormaleryth- physician-diagnosed psychiatric disorders. Dysthymic dis-

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©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 order, a mood disturbance characterized by a chronically tus were less responsive or unresponsive to therapy with depressed mood, was present in 2 patients. Prior somati- low-dose antidepressants. zation was present in 3 patients. Generalized anxiety was present in 4 patients. Of these 5 patients, 4 had psychiatric CONCLUSIONS problems that were present prior to the onset of scalp dysesthesia. Of the 11 patients we describe herein, the symp- We describe 11 women with scalp dysesthesia, a condition toms in 7 patients intensified with psychological stress. that we believe is a type of chronic cutaneous dysesthesia. A common denominator of many chronic pain syn- These women experienced debilitating scalp pain and/or dromes is improvement or complete resolution with treat- pruritus. We are not certain if our patients have pain sec- ment with low-dose antidepressants.13 Three possible ondary to underlying psychiatric conditions, such as anxi- mechanisms have been proposed14,15: first, antidepres- ety, dysthymic disorder, and somatization, or if these psy- sant use may relieve depression associated with or caused chiatric problems are unrelated or caused by the scalp dys- by chronic pain and thus improve symptoms; second, the esthesia. More studies are needed to determine the cause tricyclic antidepressants may have analgesic properties; of scalp dysesthesia and define any role psychiatric diseases and/or third, depression and pain may share a similar un- may play in causing or enhancing the pain experienced by derlying biochemical mechanism. these patients. Further studies should also formally evalu- Several placebo-controlled studies have documented ate the efficacy of treating scalp dysesthesia with low-dose the efficacy of low-dose antidepressants for treating chronic antidepressants. pain. Postherpetic neuralgia responds to treatment with amitriptyline hydrochloride as demonstrated in a double- Accepted for publication August 3, 1997. blind, placebo-controlled, crossover study.16 There was no We acknowledge Jean Vogel, MD, for performing psy- significant antidepressive effect with the low doses used (me- chiatric evaluations of 2 of our patients and Peter Lynch, dian dose, 75 mg). A 1992 placebo-controlled study17 com- MD, for providing helpful suggestions regarding therapy with pared the efficacy of desipramine hydrochloride, amitrip- low-dose antidepressants. tyline, and fluoxetine hydrochloride for treating chronic Reprints: Diane Hoss, MD, University of Connecticut pain in diabetic neuropathy. Desipramine and amitripty- Health Center, Dowling South, Suite 300, MC 6230, 263 line were equally effective and superior to placebo in both Farmington Ave, Farmington, CT 06030. depressed and nondepressed patients with diabetic neuropathy. Fluoxetine had no greater analgesic effect than pla- REFERENCES cebo in nondepressed patients. Patients who were depressed benefited from fluoxetine therapy. In a retrospective 18 1. Cotterill JA. Dermatological non-disease: a common and potentially fatal distur- review, McKay reported that dysesthetic (essential) vul- bance of cutaneous body image. Br J Dermatol. 1981;104:611-619. vodynia responds to treatment with low-dose amitripty- 2. Koblenzer CS, Bostrom P. Chronic cutaneous dysesthesia syndrome: a psy- chotic phenomenon or a depressive symptom? J Am Acad Dermatol. 1994;30: line. Gabapentin, a newly released anticonvulsant medi- 370-374. cation, has been effective in treating chronic pain syndromes 3. McKay M. 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