A SKIN DISEASE IN FORM OF DAILY PRURIGINOUS
ERYTHEMATOUS POMPHI, WITH GOOD ANSWER TO AN ANTISTRESS DRUG THERAPY. IS IT A
POSSIBLE NEW DISEASE?
Renato COCCHI, a
neurologist and a medical pychologist.
Laura GRENZI, a
dermatologist.
Summary.
A man of 35 years had a clinical history
pruriginous erythematous pomphi, as observed at the awakening, and their
missing during the day, following the possible consumption of a glutamate
excess decreased by the working activity.
We think we are dealing with a skin
disease perhaps described for the first time in the medical literature.
The night-day course led to suppose that
it was of a stress reaction, as confirmed by a great positive answer to an
antistress drugs' therapy. After six months, such pomphi are nearly all
missing, but with some recent relapse in stress conditions. Some of them
reappeared as isolate, with reduced dimensions, and without any erythema.
The psychophysical state of the patient
contemporarily improved and his personality, first much irritable, has become more
accessible.
Key words: skin, pomphi, itch, erythema,
stress, reaction, antistress, drugs, therapy.
Drug modulation of stress reactions.
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During our activity of consultation it
arrived to our observation a very curious illness of the skin, which it is then
revealed ex-juvantibus, as an illness of stress. We had the clear impression
that we could deal to an illness never described, or at least not tracked down
by us in the usual repertoires and on internet. So, we wanted to report here
its case history, as the more accurately possible, according to the Natural
Scientific Method (Cocchi, 2004) the only one applicable to the description of
clinical cases.
The case history.
A male of years 35, marry, without any son.
He lives in Lombardia and he is working as a clerk in the private sector.
Half December 2004, the report of the
Emergency Room.
He gets an intervention for the left
shoulder's dislocation. No therapies were currently in action. At the awakening
the physicians noted stains in the skin and in the scalp.
Objective examination: Maculae-papulae in
the hairy scalp and in the back. No bronchial spasm was currently found. Blood
tension = 140/80 Hg.
Diagnosis: Seborrheic dermatitis to the
hairy scalp. Urticaria-like lesions were observed in the head and in the neck.
Same day: A dermatologic consultation.
Report:
1. Seborrheic dermatitis to the hairy scalp.
2. Urticaria-like lesions in the head and in
the neck.
Suggested therapy: Oxatomide 30mg, 1 tablet
daily.
Silimarine 400mg daily for 15-30 days.
Ketoconazole for topical use on the scalp,
once every day for 7 days.
January 2005: The consultation of the
allergist.
"Since last December there was
appearance of diffused erythematous and itchy pomphi, some times with
spontaneous resolution, other times after use of antihistamine. A scopolamine
butylbromide tablet taken yesterday for cramps' pain, determined an intense and
diffused outcome. Since two weeks he stopped a therapy with tocopherol and
l-arginine, taken since a month, without any appreciable result.
Because of chronic rhinitis, in past he did
surface skin tests that were positive for the ambrosia.
Once, after an acetyl-salicylate intake, he
had diffused urticaria.
It is suggested Prick examination with
inhalants, feed, and patch test. Therapy: Fexophenadine hydrochloride 180mg,
for 15 days.
Half February 2005: Patch-test, GRDCA
series: negative;
the Prick test for foods: negative;
the Prick test for inhalating things:
positive for acaruses and ambrosia.
April 2005: General examinations: Light
reduction of the hematocrit ( 41.8 for the 42.0-54.0 range).
White blood cells' profile: Total white
corpuscles: 8550 x 10e3/uL.
Distribution: Neutrophiles 61.1%;
Lymphocytes 25.8%; Monocytes 9.76%; Eosinophils 2.76%; 0.613% Basophils. Every
parameter is in the approved ranges.
All the trial therapies did not get any
positive result.
Half June 2005: A dermatologic consultation.
He reported that since December 2004 he had the appearance of oval stain, of
marc's or cyanotic colour, large as maximum of an almond with its hull. They
distributed in all the body, not always in the same way, but having their
departure from the arms. They are much diffused on the back, but fewer also on
the legs. They have in relief body, and they give an itch.
Later they have been defined as
"erythematous and itchy pomphi", having their height of little more
than 1 mm.
They are present at the morning, to the
awakening, and they extend to widen then they to disappear during the day, when
he is going on by working. In bank holiday days they are missing slowly or
incompletely.
He consulted many experts, even
dermatologists, who did an aspecific diagnosis of the allergy.
The dermatologist had the doubt of facing an
equivalent of a psychosomatic trouble even because, Being he married since over
eight years, he doesn't succeed to have sons, for reduced mobility of the
sperms. Consulted experts told him, he has "sleepy" sperms). So, the
coauthor dermatologist required the help of the neurologist and psychologist
colleague of the same health service.
End June 2005: Neurologic and psychological
consultation. His wife is attending, and she integrates or gives some answers
that only she may know (eg. The nighttime bruxism). The strange course of the
illness suggested immediately a possible anomalous reaction of stress.
Stress symptoms: He suffers ftom the heat. Ehen he is sleeping, he
moves much. Sometimes he babbles during his sleep. No nighttime bruxism occurs,
nor drooling in the night. He denies nighttime muscular cramps and bad dreams.
Even, he remembers a few all the dreams. He wakes up tired, as if he never had
physical strenghts. He does not have breakfast, he has normal yaste for sweet
things, but he likes very much the meat broth.
In early morning, he has difficulties to
start motion. He doesn't bear the confusion and the noise, mainly that of the
vacuum cleaner. Often he realizes keeping his teeth shut. He doesn't have his
eyes burning, for no reason. Dizziness feelings occur, but not fainting ones.
Rarely mediastinal oppression happens. He never had the lump in the throat,
neither any hunger of air. Emotional hands' oversweating can come out.
Moreover, he doesn't have sudden asthenias, nor colic or diarrheas. During his
sleep, he is sweating, mainly at the nape. On holiday, by the sea, he felt
worse, and during the night he needed scratching because the itch. His hair is
fat.
Symptoms of half-brain dominance's
troubles: He was and he is a
Contrary Mary character. To the test with an immediate answer "Which is
the opposite of the colour red", he promptly answers: Green. Sometimes. He
has suddenly bad feelings against otherwise beloved persons, and he admits that
they are not a part of his personality. Usually this happens to him in the
morning. Intrusive thinking with fluctuating content occurs. He is inclining to
count objects, without any need.
Depression: Perhaps he is a little depressed, but he has not
particular greediness of milk and dairy products. His irritability, generally
and mainly in the morning, could be just a depressive symptom. Falling asleep
is well, and he doesn't need doing sex to ease his sleep. Even now he has rare
auditory hallucinations before falling asleep.
Other: Currently he attends an elimination diet, for supposed "food
intolerance".
Test therapy (daily doses, by the oral via):
Glutamine 125mg; Pyridoxine 75mg; Carbamazepine 100mg; Amitriptyline +
perphenazine 10mg + 2mg; Diazepam 2mg.
First ten days of August 2005: The first
checkup after 35 days of drug therapy. The drugs did not disturb him. He is
doing much better, his "stains" nearly disappeared. After the first
day of therapy, he had not these pomphi for 15 days, and then he had them for one
day, on his face. At the moment of the checkup he has two of them on his hands.
Now, they disappear without becoming wider. The same pomphi are now eliciting
an itch much reduced.
Stress symptoms: As compared to his wife, he bore better the heat
weather, and he is sweating less. He moved less during his sleep, and he
remembers better the dreams. Now, he wakes less tired but he continues to
refuse the breakfast. He cannot say if he bears badly the confusion and the
noise, as first. His dental shut is much diminished. The feelings of dizziness
reduced. Perhaps he has less nape perspiration during the sleep. He doesn't
know if his hair is less fat, as if he stutters still during the sleep.
Depression: He has more optimism, and he is more serene, even
if in his working place there are some problems. When he wakes up, he is less
irritable of going at work. Since a month he has no quarreling with any. Now he
is well falling asleep.
Symptoms of troubled half-brain
dominance: He doesn't count nearly
anymore. His head is more free of intrusive thoughts. He had no more bad
thoughts against otherwise beloved persons.
Other: The wife became pregnant since
the fifth day from the beginning of the therapy.
Therapeutic variation (daily doses, by the
oral via): Carbamazepine 200mg; diazepam 4mg.
End December 2005, the second checkup after
six months since the beginning of the drug therapy. He was doing well off, but
the last 15 days, as particularly stressful, he had some itchy little relapses,
but not erythematous. Today, he has a pompho behind his right ear, of a fairly
rectangular shape, of about half square cm, unfortunately not fit for a photo.
Usually the skin symptom appeared about on evening, and it lasted fewer hours.
These skin phenomena show a located itch, or there appeared even the pompho, as
little as now, but today it came out since the morning.
His job runs better, and he is much less
irritable. The parents and his wife say that he has changed his character. Now,
he agrees also with his sister, with whom he always quarrelled. He is sleeping
well. His wife said that he was turning less during his sleep. His appetite is
good, and his bowel function is now regular. He observed more strength in his
ejaculation.
Perhaps he has less dandruff, but he loses
much hair. Now, he speaks less in a hurry and he has fewer dyslalias. Bad
feelings against beloved persons reduced. He says that he increased some
kilograms, because he stopped to play football. He tried eating even things
that some physicians prohibited him, by having "diagnosed" food
intolerances, and he did not have any trouble.
The pregnancy of his wife is going on well.
The fetus is sex masculine, the cytologic examination has resulted fully
normal, and the delivery is scheduled to half April 2006.
No therapeutic variation.
Discussion.
The reported case has to be seen under a
double light. On the one hand, in literature, we did not find any description
of something of similar, mainly for its early morning aspect of having skin
symptoms at the awakening, with their spontaneous missing during the day.
Moreover, it shows a deceleration of missing such in the weekend, when the
patient was not busy in the work. On the other hand, there is nearly total
resolution following a drug therapy to modulating stress reactions.
This is to point out, if not other, that we
are dealing with a much rare illness, if not very rare, and therefore without
any report as clinical case history, in the medical literature.
Still interesting is the fact that little
relapses, after six months since the beginning of an antistress therapy, can
occur even in the evening, at the end of a stressful day. Nevertheless the
stains disappear after fewer hours, surely after the intake of the evening drug
therapy, which contains the greater amount of the antistress drugs.
Relationships between urticaria and stress
have some references in literature. Raho et al., 2003, found the presence of an
oxidative stress in the lesions from chronic idiopathic urticaria, but they
came in the conclusion that it is a secondary phenomenon to the lesion itself.
The stress seems be a fundamental component
in the idiopathic chronic urticaria, as reaffirmed by Yang and coll., in 2005.
Psychiatric and psychological factors play
an important role in 30% of skin diseases (Gupta and Gupta, 1999).
The Gardener-Diamond syndrome or the
psychogenic purpura, has a long history (Gardner and Diamond, 1955; Bagot et
al., 1984; Archer-Dubon et al., 1996; Anderson et al., 1999; Consoli, 2003,
Boussault and coll., 2005), but it differs from our case because it is a
painful purpura without any biological abnormality. It affects nearly always
young women with a pathological mental context.
As for the skin symptoms of our patient,
named "erythematous and itchy pomphi," they are not some
extraordinary things, while extraordinary was their daily course, as related to
the working activity. Such a relationship was well glimpsed by the patient
himself, who exactly reported it. When called his attention on what happened during
the weekend, the deceleration of the disappearance of those pomphi, at once led
to think about a consummation mechanism, more effective when he was working.
As a confirmation of its beginning during
the sleep, there is what happened by the sea. "On holiday, by the sea, he
felt worse, and during the night he needed scratching because the itch."
The reduced physical and working activity
and the (glutamergic?) excitement of the sea environment could be two
explanations. During the sleep too, another symptom occurs, the nape
perspiration (a common symptoms in babies, but not in more aged children and in
the adults), points out on troubles of stress reactions.
About the other early-morning troubles, an
other one is also enough indicative, the refuse to have breakfast at the usual
time. It refers the need of consuming the excess glutamate, as the
neurotransmitter of sensory pathways and the precursor of the GABA also.
(Broman, 1996). A such excess of the glutamate that forms during the sleep, has
probably two starting points. On one hand there is a smaller consumption for
reduction of the sensory inputs, on the other hand, it comes from less
transformation of it into GABA. Then, all brought to think that the critical
point was exactly the GABA.
We set up a therapy of modulation of the
GABA, with:
- A low dose benzodiazepine, to act on the
type A GABAergic receptors. Benzodiazepines, as antistress drugs, reduce the
cortisol incretion (Bruni et al. 1980; Viukari, 1983);
- A CA++ antagonist as the nimodipine, the
verapamil, or better, the carbamazepine (Crowder and Bradford, 1987) to reduce
the type B GABAergic inhibition (Liron and coll., 1985; Borman, 1988);
- The pyridoxine as the cofactor of all
decarboxylases then even of that of the glutamic acid (GAD), to favour the
transformation of the glutamate into GABA.
The things started to modify favourably
since the second day of the intake of such drugs. To improve the GABAergic
functionality wanted to say even to avoid the nighttime glutamate accumulation.
The glutamine was added as a drug against body asthenia (Cocchi, 2002), and the
amitriptyline + perphenazine was added as antidepressant and a light
antidelusional drug.
Although these are mechanisms involved in
stress, which does not mean that the patient was undergoing to a stress of
particular intensity. He could simply own a low threshold of answering to
stress. For which the stimulus, minimal for other people, for him became a
maximal one. We are dealing with differences of "an individual
field", which one of us has tried to give a theoretical base (Cocchi, 2003
).
According to the criterion ex-juvantibus, it
is nearly sure that this disturb, that showed as a skin illness, is in fact a
reaction of stress that the skin as its target symptom. To remember that either
the skin and the nervous system originate both from the same embryonic
structure, can only be a further point up of the possible relationship between
these two.
Conclusions.
This reported case history, probably the
first one in medical literature, described the presence of itchy erythematous
pomphi, observed at the awakening in a man of 35 years. These pomphi
disappeared along the day, perhaps for consumption of the glutamate excess.
Perhaps we are dealing with a very rare illness, first diagnosed as allergy and
treated consequently, without any results. The odd night-day course of it,
suggested a possible stress reaction, confirmed from a great positive response
to an antistress drug therapy. Six months later, such pomphi nearly missed,
with some relapse in stress conditions, where they reappeared with smaller
intensity. The psychophysical comfort of the patient improved, and his
personality, much irritable, became more willing, as even said by his wife and
his parents.
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Posted on internet on 14
November 2006. Copyright by Renato Cocchi 2006
Author's address: dr. Renato Cocchi, via
Rabbeno 3
42100 Reggio Emilia
renatococchi@libero.it
Drug modulation of stress reactions.
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