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Primary Erythromelalgia: a Review Zhaoli Tang1, Zhao Chen1, Beisha Tang1,2,3 and Hong Jiang1,2,3*

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Primary Erythromelalgia: a Review Zhaoli Tang1, Zhao Chen1, Beisha Tang1,2,3 and Hong Jiang1,2,3* Tang et al. Orphanet Journal of Rare Diseases (2015) 10:127 DOI 10.1186/s13023-015-0347-1 REVIEW Open Access Primary erythromelalgia: a review Zhaoli Tang1, Zhao Chen1, Beisha Tang1,2,3 and Hong Jiang1,2,3* Abstract Primary erythromelalgia (PE ORPHA90026) is a rare autosomal dominant neuropathy characterized by the combination of recurrent burning pain, warmth and redness of the extremities. The incidence rate of PE ranges from 0.36 to 1.1 per 100,000 persons. Gender ratio differs according to different studies and no evidence showed a gender preference. Clinical onset of PE is often in the first decade of life. Burning pain is the most predominant symptom and is usually caused and precipitated by warmth and physical activities. Reported cases of PE contain both inherited and sporadic forms. Genetic etiology of PE is mutations on SCN9A, the encoding gene of a voltage- gated sodium channel subtype Nav1.7. Diagnosis of PE is made upon clinical manifestations and screening for mutations on SCN9A. Exclusion of several other treatable diseases/secondary erythromelalgia is also necessary because of the lack of biomarkers specifically for PE. Differential diagnoses can include Fabry disease, cellulites, Raynaud phenomenon, vasculitis and so on. Diagnostic methods often involve complete blood count, imaging studies and thermograph. Treatment for PE is unsatisfactory and highly individualized. Frequently used pain relieving drugs involve sodium channel blockers such as lidocaine, carbamazepine and mexiletine. Novel drugs such as PF-05089771 and TV-45070 could be promising in ameliorating pain symptoms due to their Nav1.7 selectivity. Patients’ symptoms often worsen over time and many patients develop ulcerations and gangrenes caused by excessive exposure to low temperature in order to relieve pain. This review mainly focuses on PE and the causative gene SCN9A – its mutations and their effects on Nav1.7 channels’ electrophysiological properties. We propose a genotype-channelopathy-phenotype correlation network underlying PE etiology which could provide guidance for future therapeutics. Keywords: Primary erythromelalgia, Voltage-gated sodium channel, Pain, Genetics, Electrophysiology, Hyper-excitability, Therapy Introduction burning pain, warmth and redness of the extremities. The Pain, under physical conditions, informs body of harmful causative gene for PE, SCN9A, encodes a voltage-gated so- stimuli, elicits protective reflexes, making it essential for dium channel (VGSC) subtype Nav1.7. Series of researches survival. Pathological pain, on the other hand, is one of on PE have elucidated a close relationship between aberrant the most prevalent symptoms seen in patients. Chronic electrophysiology of VGSC (in this case Nav1.7) and hyper- pain has become a global health problem which is esti- excitability of peripheral nociceptive neurons. PE plays a mated to affect about 30 % of adults worldwide [1]. pivotal role in understanding the molecular mechanisms Currently used drugs such as opioids and non-steroidal underlying pain caused by neuron hyperexcitability. This anti-inflammatory drugs (NSAIDs) show limited efficacy review mainly focuses on PE and the causative gene SCN9A [2]. Thereby more precise medications for various types – its mutations and their effects on Nav1.7 electrophysio- of pain rising from different etiologies are required. As logical properties. We also recapitulate utilization of one of the human heritable pain disorders, primary erythro- current treatments and updates of novel Nav1.7-targeted melalgia (PE) is characterized by the triad of recurrent agents, and propose an integrated perspective of a genotype-channelopathy-phenotype network underlying * Correspondence: [email protected] this intricate condition. 1Department of Neurology, Xiangya Hospital, Central South University, 87 Xiangya road, Changsha 410008, Hunan, China 2Key Laboratory of Hunan Province in Neurodegenerative Disorders, Central South University, 87 Xiangya road, Changsha 410008, Hunan, China Full list of author information is available at the end of the article © 2015 Tang et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Tang et al. Orphanet Journal of Rare Diseases (2015) 10:127 Page 2 of 11 Definition leg dependence and wearing shoes or gloves can provoke PE is a rare autosomal dominant neuropathy character- and aggravate PE symptoms while immersion in ice/cold ized by the triad of burning pain, recurrent redness, and water, uncovering affected areas, ventilation and eleva- warmth of the extremities. tion can ameliorate these symptoms [39]. In some cases the symptoms precipitated during puberty, implicating a Nomenclature and classification hormonal role in PE pathophysiology [40]. This rare and debilitating disorder was first reported and Pain is the most disturbing symptom affecting PE pa- named “erythromelalgia” according to its main symp- tients and can be disabling. The pain is usually bilateral, toms (erythros-red, melos-limbs, algos-pain) by Mitchel intermittent and severe, more often involving lower ex- in 1878. Later the name “erythromelalgia” and “eryther- tremities than upper extremities [39]. Besides extrem- malgia” were used respectively for cases secondary to ities, body parts such as hands and auricles being myeloproliferative disorders and idiopathic cases that affected have been reported [41]. Pain attacks usually were refractory to aspirin. At present, erythromelalgia is start with an itchy-like feeling and then progress to a se- classified into PE and secondary erythromelalgia, based vere burning sensation as was reported by most patients, on the absence or presence of diseases or drugs that with the durations of which ranging from several mi- may associate with the onset or precipitation of its nutes to hours and even days. Pain symptoms are worse symptoms [3, 4]. PE is exclusively caused by mutations in summer and at night and are usually provoked and in SCN9A, the encoding gene of sodium channel subtype exacerbated by heat, ambulation, physical exercise, sit- Nav1.7 and can be sub-classified into familial (inherited ting, leg dependence, and coverage of extremities [40]. erythromelalgia) and sporadic forms. Secondary erythro- Cooling and elevation are most effective ways to relieve melalgia is often associated with myeloproliferateive dis- pain symptoms. According to patients, they would im- orders. In some cases, secondary erythromelalgia occurs merse affected limbs in ice water, uncover their feet dur- in paraneoplastic diseases and autoimmune neuropa- ing sleep or walk barefoot in winter. Affected extremities thies. Though very rare, secondary erythromelalgia can can develop ulceration and gangrene which are not dir- also appear in diabetes, rheumatologic diseases and in- ectly attributable to PE but are results of excessive ex- fectious diseases [5–9]. posure to low temperature [42]. Apart from the common clinical descriptions, there Epidemiology have been several reports about atypical PE cases with PE is a rare neuropathy. Little is known in terms of the comorbidities. Takahashi et al. described a PE patient global prevalence of PE. In a Norwegian clinical study of with wintry hypothermia and encephalopathy [43]. 87 patients with Erythromelalgia, the estimated annual Meijer et al. reported a case of PE patient with global prevalence was 2/100,000 with primary cases making up motor decay [14]. two-thirds of all cases [10]. A recent study in Sweden re- ported that the incidence of erythromelalgia was 0.36/ Etiology 100,000 though no incidence data regarding primary Genetics form was shown [11]. In a population-based study in The causative gene for PE, SCN9A (GenBank: Olmsted County, USA, the incidence was reported 1.3/ DQ148960.1), was first identified and reported by 100,000. Male-to-female ratio of erythromelalgia differs Yang et al. in 2004 [36]. SCN9A encodes Nav1.7, a greatly in the aforementioned studies [12]. However, member of the VGSC family. Nav1.7 is preferentially these studies included both primary and secondary expressed in small-diameter nociceptive neurons and forms of erythromelalgia, therefore providing limited in- can be up-regulated in the context of inflammation formation about prevalence/incidence of PE. Patients re- [44]. It is now well characterized that Nav1.7 plays a ported present diverse nationalities (Chinese, American, pivotal role of “threshold gate” in the generation of French, Dutch, Norwegian etc.) and geographical back- action potentials for its ability to amplify small, slow grounds [13–36]. depolarizations and thus bringing the membrane po- tential closer to the voltage threshold of action poten- Clinical description tial [45]. Due to the strong dependence of the action PE is characterized by the hallmark triad of recurrent potential on Nav1.7 in nociceptive neuron cells, mo- redness, burning pain, and warmth of the extremities in lecular alterations in Nav1.7 caused by SCN9A muta- virtue of exposure under heat, exercise and gravity and
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