Sir,Trigeminal trophic syndrome (TTS) is a rare condition resulting from self-manipulation of the skin after peripheral or central injury to the trigeminal system.[1] It was recognized in the early 20th century when neurosurgeons began to perform trigeminal rhizotomy to treat the debilitating pain of trigeminal neuralgia. It was later noticed that some of these patients developed ulcers on or to the side of their nostrils after the procedure.[2] TTS is a relatively unrecognized entity among dermatologists and may lead to misdiagnosis. We therefore, report a case of TTS who had been mistreated for herpes zoster twice.A 72-year-old man was seen with 1 year history of a painless, irregular, nonhealing ulcer covered with hemorrhagic crusts affecting the left ala nasi [Figure 1]. A few erosions with patchy depigmentation were also present over scalp [Figure 2]. The patient admitted to repeated rubbing and picking the skin of the affected areas due to paresthesia since last two years. He had undergone trigeminal neurectomy two years back for severe episodic, paroxysmal pain affecting left half of face since last five years. He received acyclovir twice, without any apparent benefit, in the past for presumed diagnosis of herpes zoster. However, there was no history of painful grouped vesiculobullous lesions. Chronicity of the condition, absence of vesiculobullous lesions, sensory loss, habitual rubbing, and past history of trigeminal neurectomy pointed toward the diagnosis of TTS.
Figure 1
Irregular ulcer covered with hemorrhagic crusts over left ala nasi
Figure 2
Erosions and postinflammatory depigmentation over scalp (the yellow color on the scalp is due to application of turmeric powder by the patient)
Irregular ulcer covered with hemorrhagic crusts over left ala nasiErosions and postinflammatory depigmentation over scalp (the yellow color on the scalp is due to application of turmeric powder by the patient)TTS consists of a triad of anesthesia, paresthesia, and a secondary persistent or recurrent facial ulceration. It results secondary to self-manipulation of the skin after peripheral or central injury to the trigeminal system.[1] Important causes of this syndrome include trigeminal ablation, infarction, vertebrobasilar insufficiency, acoustic neuroma, astrocytoma, meningioma, spinal cord degeneration, Mycobacterium leprae neuritis, herpes zoster, syringobulbia, postencephalitic parkinsonism, and trauma.[3] Lesions of TTS most commonly occur in the second trigeminal division dermatome, followed by the first and third and the tip of the nose is often spared.[13] Differential diagnoses include infectious causes of ulceration, malignancy, and dermatitis artefacta. The presence of sensory loss is an important sign that may indicate TTS.[4]The treatment of TTS is challenging. Behavioral modification, pharmaceutical intervention, use of protective dressings, transcutaneous nerve stimulation, and surgical repair are some of the options; although none has been found to be consistently effective.[1] Recognition of TTS among clinicians is important to avoid misdiagnosis and mistreatment. This was seen in our case too who was needlessly treated for herpes zoster twice.
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Figure 1
Figure 2