A 43-year-old woman with a history of depression and arthralgia developed a complex regional pain syndrome type-1 (CRPS-1) after a distal radius fracture. Five months later skin changes, progressive pain and dysfunction prompted evaluation for autoimmune diseases. Therapy had included dimethylsulfoxide and capsaicin salves, N-acetylcysteine, vitamin C, diclophenac and pregabaline. Physical examination revealed an atrophic immobile left hand and forearm with discolorations and armour-plated skin. There were no signs of autoimmune or infectious disease. She appeared to apply salves intensively without cleaning, resulting in armour-plated salve with desquamated skin (fig 1A). This was gradually removed by judicious cleaning (fig 1B,C). Thereafter, a short course of prednisone improved the CRPS-1-related symptoms.

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Figure 1

(A) Atrophic immobile left hand and forearm with discolorations and armour-plated skin (week 0). (B) Gradual removal of armour-plated salve and desquamated skin (week 1). (C) Result after judicious cleaning and a short course of prednisone (week 8)

CRPS-1 is a complication of tissue injury without definable nerve lesion, leading to hyperalgesia, clinical impairment and disability. Typical dermatological symptoms are atrophic lesions and skin thickening. Mast cells and proinflammatory cytokines such as interleukin 1β (IL1β), IL6 and tumour necrosis factor α (TNFα) are associated with disease activity. Few controlled studies regarding treatment have been published. Free radical scavengers, such as topical dimethylsulfoxide or N-acetylcysteine, might inhibit the excessive inflammatory response induced by toxic oxygen radicals, and are shown to be effective.1 Capsaicin salve is used to release and deplete substance P from sensory nerve fibres.2 Short course systemic corticosteroids can improve symptoms in >75% of patients with refractory CRPS-1.3 However, adequate treatment of this complex syndrome might require a multidisciplinary approach. As shown in this unique case, on the other hand, excessive desperately applied salves will not improve their therapeutic effectiveness.