Abstract
Erythromelalgia is a rare neurovascular syndrome characterized by intense, episodic burning pain that primarily affects the feet and hands and, occasionally, the face. Symptoms are often triggered by heat and exercise, with relief typically achieved through cooling methods. However, improper use of these techniques can lead to serious complications, such as trench foot and cellulitis. The condition can also have significant psychological effects, contributing to anxiety and depression. An 18-year-old Lebanese woman with primary erythromelalgia and a family history of the condition presented with worsening bilateral pain and erythema in her lower extremities. Her pain was poorly controlled, prompting her to engage in prolonged ice-water immersion, which resulted in skin abrasions, necrotic ulcers, and cellulitis. On admission, she exhibited bilateral lower extremity erythema, edema, tenderness, and macerated skin with necrotic ulcers on her left foot. Her nails showed white discoloration and onycholysis. Laboratory tests were normal, and Doppler ultrasound revealed increased blood flow, supporting the diagnosis of erythromelalgia. A multidisciplinary team managed her care, addressing infection, pain, and anxiety. She received antibiotics, wound care, and antifungal therapy for onychomycosis. Pain management included aspirin, pregabalin, topical lidocaine, acetaminophen, nefopam, and opiates; however, due to persistent pain, her regimen was adjusted to incorporate morphine and additional agents. Duloxetine was also introduced to address both anxiety and pain. After two days on the revised treatment plan, her pain improved significantly, allowing for discharge. Follow-up visits confirmed skin healing, and Doppler ultrasound again demonstrated increased blood flow. This case highlights the complexity of managing severe erythromelalgia, underscoring the importance of appropriate pain management, patient education, and multidisciplinary care. It represents the first reported case of erythromelalgia requiring hospitalization in Lebanon and illustrates the potential complications of inadequate management and inappropriate use of cooling techniques.