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Complex regional pain syndrome of the face in a child

A 13-year-old-boy was referred to the Pediatric Dermatologic Unit with a 2-year history of left-sided facial swelling and pain with redness and burning sensation. He was specifically referred to dermatology because of the pronounced skin changes and the lack of a diagnosis. Prior to the onset of the symptoms, he was struck on the left side of his face with a tennis ball and over 5 days developed swelling, redness, cold, and allodynia. The patient had been treated with oral corticosteroid, gabapentin, and topical anesthetic cream without improvement. Physical examination detected mild erythema as well as swelling along with impairment of movement of the left musculus frontalis with limitation for raising the left eyebrow (Fig. 1). Palpation of the affected area revealed allodynia to the left side of his face. He was out of school for 1 year because of his pain. Differential diagnosis included traumatic injury, infection, inflammatory conditions, mainly Melkersson-Rosenthal syndrome and Morbihan disease, and CRPS. Subsequent routine laboratory analyses and multiple investigations including computerized tomography scan, magnetic resonance imaging scan, and skin biopsy were normal. He was also assessed by neurology and ophthalmology who found no cause for his symptoms. After these extensive investigations as well as the presence of allodynia, vasomotor, and sudomotor changes and motor impairment, he was diagnosed with CRPS type 1. Pharmacologic therapy was stopped and he began outpatient physical and occupational therapy three times a week with a rigorous home exercise program. His therapy was focused on function, using the affected area of the face, and desensitization. Over 3 weeks, he regained full function, and his pain resolved. He has had no recurrence in 9 months.