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 com- pletely 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 objec- tive 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 ARCH DERMATOL / VOL 134, MAR 1998 327 ©1998 American Medical Association. 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Downloaded From: https://jamanetwork.com/ on 10/01/2021 Characteristics of Women With Scalp Dysesthesia* 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 postmeno- pausal 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) ARCH DERMATOL / VOL 134, MAR 1998 328 ©1998 American Medical Association. 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Downloaded From: https://jamanetwork.com/ on 10/01/2021 Characteristics of Women With Scalp Dysesthesia* (cont) 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%)