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Trigeminal trophic syndrome

SIR, All who have been in clinical practice for several years will have had under their care patients with this difficult problem, so well described by Westerhof & Bos (British Journal of Dermatology 1983, 108, 601). Those I have seen have been confused elderly women each of whom had undergone various forms of surgical destruction of the trigeminal nerve for the relief of severe trigeminal neuralgia. One of my patients was able to describe her symptoms vividly and although the area supplied by the destroyed nerve was anaesthetic to all the usual tests, she experienced a peculiar sensation of 'things crawling under her skin' which gave her an uncontrollable urge to pick the paraesthetic area, producing the characteristic indolent painless ulcers. As the authors say, these heal under occlusion but it is impossible to keep this particular site occluded for any length of time. I was most interested in their method of treatment. It is well known that repeated rhythmical stimulation of a sensory nerve will lead to diminished sensation and I wondered whether in addition to improving the blood supply of the area the transcutaneous electrical stimulation was also diminishing the altered sensation responsible for the peculiar paraesthesia. The fact that the condition relapsed some weeks after stopping the treatment but responded again to further stimulation would be in favour of a temporary diminution of sensation produced by repeated electrical stimulation of the affected nerves. I have also seen similar 'trophic' lesions following severe herpes zoster of the ophthalmic division of the trigeminal nerve. These patients also had peculiar sensations in the affected area.