INTRODUCTION
Reflex sympathetic dystrophy (RSD), is a subcategory of complex regional pain syndrome (CRPS), a term which encompasses many entities identified in the literature such as causalgia and algodystrophy.1,2 A hallmark of CRPS is localized post-injury extremity pain that is out of proportion to what would be expected after a similar trauma. Other manifestations of CPRS include autonomic abnormalities, motor dysfunction, and increased bone resorption.3 Notably, a variety of hair, nail, and skin changes have been described to occur in association with CPRS.4-6 Dermatologic findings can be non-specific, and therefore are difficult to associate definitively with CRPS in individual patients.5 Because the cutaneous signs are often misdiagnosed as other conditions with similar skin findings, it is imperative for dermatologists to understand the diversity of cutaneous manifestations of CRPS.5,7 We present a case of a patient with long-standing RSD in order to provide a guided review of previously described dermatologic manifestations of RSD while detailing newly described potential features of the disease.
CASE REPORT
Our patient is a 52-year-old Caucasian female with a 19-year history of RSD developing after a non-displaced left tibia fracture suffered while hiking. Persistent pain and swelling despite bracing and physical therapy led to a formal diagnosis of RSD six months following the onset of symptoms. She initiated care with a pain specialist and embarked on a lengthy treatment course involving systemic steroids, nerve block treatments, epidural ropivacaine 0.1% infusion treatments, intravenous ketamine infusions, phenoxybenzamine, nifedipine, gabapentin, pregabalin, transdermal lidocaine patches, and transdermal clonidine patches. In addition to hallmark CRPS pain symptoms, she experienced secondary Raynaud’s symptoms in her feet bilaterally, which improved with diosmiplex. Furthermore, the patient has experienced a variety of dermatologic manifestations including vasculitis, nail changes, lidocaine insensitivity, localized hypotrichosis, and facial telangiectasia.
Leukocytoclastic Vasculitis
Our patient has reported intermittent episodes of a mildly tender rash appearing as multiple clustered non-blanching and non-palpable petechiae on the lower legs bilaterally. At times, the rash was pruritic. A punch biopsy of a characteristic lesion (Figure 1A) revealed a mild superficial perivascular and interstitial neutrophilic infiltrate with leukocytoclasia, rare eosinophils, sparse superficial perivascular lymphocytes, and mild erythrocyte extravasation. No systemic involvement was identified and symptoms resolved with topical steroids.Vasculitis has been previously described in patients with RSD.8-10 Webster et al presented a case series including two RSD
