The most prominent presenting symptom in this disorder is the recurrent episodes of erythema and painful burning sensation mainly affecting the upper or lower limbs. The pain is normally burning type with tenderness and shooting or a radiating pattern. The pain usually affects lower extremities and the symptoms can also affect the ears and face. In the lower limbs, soles and toes of feet are commonly affected, very rarely involving the knees. In the upper extremities, both hands and fingers are affected. Mostly both upper as well as lower extremities are affected bilaterally.

The characteristic symptom of erythromelalgia is warm, red, tender and painful hands and legs, aggravated by warmth or hanging the limb downwards which is classically ameliorated by cool application and elevation. Burning pain in paroxysms is a cardinal sign of this disorder.
Sometimes the episodes last for an hour or two, while other times there is persistent pain. Flare ups are also a common occurrence wherein the attack starts with itching followed by burning and pain sensation. Theses flare ups can last for a few minutes to a whole day.
During an episode of erythromelalgia the extremity appears warm, tender, swollen and looks mottled. The pain can be so excruciating that it can disrupt normal functioning of the patient.
Common triggers of episodes of pain are alcohol, tea, caffeine, pressure and warmth. Symptoms of Raynaud's phenomenon are known to occur in between attacks of erythromelalgia. This is purely coincidental and there seems to be no correlation between the two. The burning pain is so intense that patients avoid usage of socks as it generates more heat, triggering an attack, and prefer to stay in cooler places.

• Pain

  From genes to pain: Na v 1.7 and human pain disorders. Trends Neurosci. 2007 Nov;30(11):555-63. Epub 2007 Oct 22. Review. Dib-Hajj SD, Cummins TR, Black JA, Waxman SG. Sodium channels in normal and pathological pain. [ghr.nlm.nih.gov]

  For many patients, multiple pain medications have been useless in achieving complete relief of pain symptoms. [pediatrics.aappublications.org]

  Erythromelalgia, which literally means red, painful extremities, describes an exceedingly rare, chronic condition that is characterized by the clinical triad of pronounced erythema, painful burning, and elevated skin temperature usually around the extremities [medlink.com]

  This patient’s pain was debilitating, and was poorly controlled despite being treated with high-doses of neuropathic pain medication. [omicsonline.org]

• Burning Pain

  Erythromelalgia is distressing paroxysmal vasodilation of small arteries in the feet and hands and, less commonly, in the face, ears, or knees; it causes burning pain, increased skin temperature, and redness. [msdmanuals.com]

  Erythromelalgia is a rare syndrome that is characterized by episodic attacks of burning pain, erythema, and increased temperature usually affecting the extremities, which is aggravated by warmth or exercise. [ncbi.nlm.nih.gov]

  Synonym(s): Mitchell disease, red neuralgia. [ erythro- + G. melos, limb, + algos, pain] erythromelalgia Mottled redness and a painful burning sensation in the extremities, usually the feet, with a local rise in skin temperature. [medical-dictionary.thefreedictionary.com]

  pain in the affected sites. [icd9data.com]

• Disability

  The authors present a 65-year-old woman with erythromelalgia of the ears with disabling symptoms whose diagnosis was delayed for 6 years. [ncbi.nlm.nih.gov]

  Symptoms may remain mild for years or become severe enough to cause total disability. Generalized vasomotor dysfunction is common, and Raynaud syndrome may occur. Diagnosis of erythromelalgia is clinical. Testing is done to detect causes. [msdmanuals.com]

• Severe Pain

  Severe pain responded to the use of regional anaesthetic blocks. [ncbi.nlm.nih.gov]

  Presentation Severe pain, heat and flushing of the legs, usually episodic in nature. [bigtomato.org]

• Gangrene

  This can also lead to maceration of the skin, non-healing ulcers, infection, gangrene and amputation. Topical therapy Topical capsaicin cream has been reported with varying results. [dermnetnz.org]

  If left untreated, they may progress towards acrocyanosis and even peripheral gangrene. This clincal entity can present months to years prior to an official diagnosis of a MPD. [bloodjournal.org]

• Dependent Rubor

  Abstract Leo Buerger, MD, was the first to describe dependent rubor associated with marked atherosclerosis. [ncbi.nlm.nih.gov]

• Erythema

  We describe a 14-year-old female who presented with erythema, burning sensation, and warmth on her face only, which mimic the features of erythromelalgia. [ncbi.nlm.nih.gov]

  Fig. 1: Dermal erythema of feet Fig. 2: Dermal erythema of hand Evaluation for plantar fasciitis, malignancy, immune diseases and blood dyscrasia was negative. [chanrejournals.com]

  Journal of Medical Case Reports volume 3, Article number: 106 (2009) Cite this article 47k Accesses 14 Citations 1 Altmetric Metrics details Abstract Introduction Erythromelalgia is a rare disorder characterized by episodic erythema and burning pain, [jmedicalcasereports.biomedcentral.com]

• Flushing

  Presentation Severe pain, heat and flushing of the legs, usually episodic in nature. [bigtomato.org]

  To date, she continues to avoid any activity that might precipitate any flushing and burning events. [jmedicalcasereports.biomedcentral.com]

  [Journal Article] BMJ Case Rep 2019; 12(10)Patel P, Zhang Y, … Edwards CBC Erythromelalgia (EM) is a rare disorder of small nerve fibres that leads to painful flushing and burning paresthesisas of the distal extremities and is typically associated with [unboundmedicine.com]

  But urinating after sex helps to flush bacteria from your system. Consume plenty of liquids. Drinking water (especially after intercourse) helps dilute urine and spur more frequent urination, which flushes E. coli from the urinary tract. [everydayhealth.com]

• Urticaria

  Many differentials mimic EM, as urticaria/hives, vasculitis and athlete's foot. - Bloodwork and analyses to identify underlying conditions that may cause secondary EM. - Genetic testing in those aged under 28 or with a family history of EM. [cloudywithachanceofpain.com]

  Derm Coding Consult AAD Meeting News Aspire Other publications AAD Apps Dermatology Daily DW Weekly Directions in Residency Young Physician Focus Academy Meeting app JAAD app JAAD Case Reports app Dialogues in Dermatology app MyDermPath app Chronic urticaria [aad.org]

• Foot Pain

  The patient reported severe ongoing foot pain, which was exquisitely sensitive to limb cooling. We confirmed this heat hypersensitivity using quantitative sensory testing. [ncbi.nlm.nih.gov]

  Contents 1 Achilles tendon inflammation (tendinitis) 2 Arthritis (arthritis of the foot) 3 Osteoarthritis and foot pain 4 Stress fracture 5 Mucositis of the foot 6 Tendonitis and foot pain 7 Erythromelalgia and foot pain 8 Athlete's foot 9 Foot warts [bindevevssykdommer.no]

  Within several days, she was seen as an outpatient in the Pain Management Center. Her pain had at this point persisted for 6 weeks, and she had developed trench foot as a result of prolonged immersion in ice water. [anesthesiology.pubs.asahq.org]

  The patient's pain stabilized at 4 to 6 episodes per day, with occasional foot soaks at night. [pediatrics.aappublications.org]

• Peripheral Neuropathy

  Secondary erythromelalgia can result from small fiber peripheral neuropathy of any cause, polycythemia vera, essential thrombocytosis, hypercholesterolemia, mushroom or mercury poisoning, and some autoimmune disorders. [dbpedia.org]

  Association with small fiber neuropathy and axonal large fiber peripheral neuropathy has been described. Erythromelalgia in the setting of acquired demyelinating neuropathy has not been reported. [ncbi.nlm.nih.gov]

  Peripheral neuropathies underlie many, and in some cases EM may be secondary to other disorders like the blood disease polycythemia. A number of different medications have been shown effective in relieving symptoms of EM. [web.archive.org]

  Erythromelalgia is often considered a form of peripheral neuropathy because it affects the peripheral nervous system, which connects the brain and spinal cord to muscles and to cells that detect sensations such as touch, smell, and pain. [ghr.nlm.nih.gov]

• Burning Sensation

  We report on a 7-year-old boy who had episodes of reddening, swelling and a burning sensation in one ear with local hyperthermia persisting for 3 years. [ncbi.nlm.nih.gov]

  # add ice to bottom Bangladeshi innovator Ashis Paul has built an incredible zero-electricity air conditioner, called Eco Cooler, using discarded plastic bottles Home Remedies for Burning Sensations in Feet Home Remedies for Burning Sensations in Feet [pinterest.de]

• Numbness of the Hand

  Her left upper arm was first, then the pain appeared to cross her torso and afflict her right arm as well, finally resulting in her complaining of bilateral numbness in her hands and feet. [pediatrics.or.kr]

A thorough history and investigation for underlying disease should be done. Erythromelalgia maybe indicate signs of polycythemia or thrombocytopenia. Relief with aspirin guides the physician in diagnosis [7].
Due to periodic episodes of pain, clinical examination may be difficult unless a patient is able to provide a correct and accurate picture of pain and symptoms. Between attacks, physical examination is normal. However, if any doubt exists, application of heat or warmth on the affected extremities can trigger an attack to confirm diagnosis. During an episode of pain [8], the affected extremity on palpation is warm, tender, appears red and mottled. Very rarely the disorder progresses to necrosis or ischemic ulceration. This occurs with secondary infection. Palpating for splenomegaly and lymphadenopathy should be done during physical examination for suspected cases of erythromelalgia.

Laboratory investigations include a complete blood count along with differential count to detect any underlying myeloproliferative disorder. Keep a tab on platelet counts as well as hematocrit levels. Other laboratory tests are nonspecific. Thermography [9] is done to detect temperature rises of affected extremity, but this not a diagnostic test. Histologically, a decreased capillary density and capillary perfusion is observed. Other than a proper clinical history there is no definite diagnostic test for erythromelalgia. Investigations should be done to detect any underlying myeloproliferative diseases or blood dyscrasias. Often it might take even months for doctors to come to a diagnosis.

• Thrombocytosis

  All previous reports about erythromelalgia that is the result of a myeloproliferative process have documented associated thrombocytosis. [ncbi.nlm.nih.gov]

  Most reported cases of secondary erythromelalgia are due to myeloproliferative disorders with thrombocytosis (Polycythemia vera or essential thrombocytosis are most common). [boneandspine.com]

  Abstract Cutaneous manifestations of myeloproliferative disorders (MPD) herald an uncommon diagnostic clue preceding a diagnosis of Essential Thrombocytosis (ET) and Polycythemia Vera (PV). [bloodjournal.org]

  Symptomatic responses have been reported to aspirin therapy (for erythromelalgia related to thrombocytosis), sodium nitroprusside, propranolol, high dose magnesium, lignocaine patch, amitriptyline and gabapentin. 4-8 The involvement of secondary causes [chanrejournals.com]

Therapy for both primary and secondary erythromelalgia includes medications, general conservative measures and surgical options. In secondary erythromelalgia, it is vital to treat the underlying  cause of the disorder. Symptomatic treatment is followed for primary cases of erythromelalgia.
Drug therapy includes a number of oral medications such as aspirin which relieves symptoms of erythromelalgia with underlying myeloproliferative diseases. Antidepressants and anticonvulsants are also given. Sometimes an individual's response to drugs is variable and may show a better reaction with a combination of medications. Intravenous medications of prostaglandin and nitroprusside are also given [10].
General measures include cooling and elevation of affected limb. Constant cooling is not advisable as it will only provide temporary relief. Other complicated problems can arise due to constant cooling for differences in temperature which will result in frequent flare ups. This can further lead to skin maceration, ulceration, gangrene and amputation. Avoidance of hot surroundings to prevent any attack is essential. Vigorous exercise can also trigger an episode of intense pain and are not recommended. No special dietary considerations are advised for this disorder.
The scope of surgical options in the treatment of erythromelalgia is very limited and does not play a significant role. Sympathectomy has been done wherein the sympathetic nerve fibers have been cut to help in cutting off the pain sensation.

There is no single drug therapy for this disorder and patients show a variety of responses to drugs. Remission of erythromelalgia is quite frequent and common. People who respond well to aspirin show less morbidity and remission. Early onset cases of erythromelalgia are more stubborn to treat and show variable response to drugs. Complications are less frequent and occur more in individuals with a platelet disorder. Ulceration, necrosis and gangrene are common complications which can occur on the affected extremities. Repeated ulceration or necrosis can lead to infection which may require amputation. Otherwise, most cases can be controlled with drugs without disturbing an individual's daily activities.

Erythromelalgia can be classified into primary erythromelalgia or secondary erythromelalgia depending on the underlying cause [2]. Primary erythromelalgia usually occurs due to an unknown cause i.e. idiopathic. These cases usually happen spontaneously at any age with no underlying trigger. But some genetic mutations can be accounted for the causation of primary erythromelalgia, like those in a gene called Na (v) 1.7 which basically encodes for sodium ion channel within cells.
Secondary erythromelalgia occurs due to some underlying pathology or some medical conditions. Most common causes of secondary erythromelalgia are myeloproliferative disorders wherein the bone marrow produces excessive cells such as in polycythemia vera or thrombocytopenia. In almost 80% of cases, erythromelalgia occurs prior to onset of myeloproliferative disorders.
Other causes of secondary erythromelalgia include neurological diseases such as multiple sclerosis and peripheral neuropathy and autoimmune diseases such as lupus. Early onset [3] erythromelalgia usually occurs before the age of 25, while the mean age for late onset of erythromelalgia is 61 years. Both these types are primary in etiology with an inherited link.

Most patients of primary erythromelalgia are usually women. Early onset primary erythromelalgia is slightly rarer as compared to cases with underlying myeloproliferative diseases. Recent studies show that erythromelalgia is becoming more common with every decade. Many cases may go unnoticed due to lack of knowledge of this rare disease. Early onset cases usually have a median age of ten years of onset while adult onset erythromelalgia cases start by the fifth or sixth decade. Pediatric cases have a variable progress and onset and are mostly accompanied by a considerable degree of morbidity and can be even fatal in some occasion. Incidence of erythromelalgia is more prominent in females with the early onset cases having a male to female ratio of 1:2.5, while secondary erythromelalgia has a male to female ratio of 3:2 with most of the cases due to myeloproliferative diseases. In U.S., the incidence of erythromelalgia cases is about 1.3 per 10000 people every year with women being about 2 per 10000 people and men being only about 0.6 per 10000 [4]. The mean age of detection and diagnosis is around 61 years of age.

The basic pathological findings in erythromelalgia are mainly microvascular shuntings. Erythromelalgia is considered more a complex disease than a defined condition by itself. This hypothesis suggests microvascular arteriovenous shunting [5] along with spontaneously occurring tissue hypoxia and hyperemia. Therefore, inflammation happens due to some infection, trauma or tumor. This AV shunting can be induced because of a variety of conditions. The postulated hypothesis suggests that the hypoxia results due to irregularities in blood flow in the skin along with reduced nutritional perfusion and increased thermoregulatory perfusion. In addition to this, there is some neurogenic pathway also responsible for hyperactivity and hypersensitivity of C-fibers and postganglionic dysfunction of sympathetic nervous system. Thus, this seems to be the postulated pathway in pathway in primary erythromelalgia.

Secondary erythromelalgia is associated with some underlying disorder, usually thrombocytopenia. Biopsy samples of skin have showed arteriolar fibrosis and occlusion with thrombi of platelets. Decreased platelet survival along with excessive aggregability of platelets has been noted too. In cases with no underlying thrombocytopenia, the pathology is less clearly understood. In inherited cases of erythromelalgia, certain genetic mutations of sodium ion channels that are expressed in peripheral nerves have been seen. These mutations cause dorsal root ganglion neuron excitability along with a delayed onset of clinical symptoms. Molecular biology may have the answers for understanding this disorder [6].

Since there is no known cause for this disorder, there are no definite preventive measures. Certain general measures of prevention to avoid pain attacks include:

• Avoiding very hot surroundings
• Avoid wearing socks or gloves in summer
• Do not indulge in very vigorous activity
• Refrain from intake of alcohol, caffeine and other stimulants

Intake of food rich in Vitamin B such as whole grains, brown rice, peanuts and dairy products can improve immunity and help in ameliorating pain symptoms. These methods might be enough to bring cases of primary erythromelalgia in control.

Erythromelalgia is a rare skin condition which typically affects the skin of the hands and feet and rarely the face and other parts of the body. This condition is primarily characterized by burning heat, redness and intense pain. This rare disorder is also termed as Mitchell's disease after the person, Silas Weir Mitchell, who described it. The name of this condition is derived from 3 Greek words- "erythros" meaning red, "melos" meaning limbs and "algos" meaning pain. Frequently, this condition is also known as acromelalgia, red neuralgia or erythermalgia. This condition is an uncommon peripheral vascular disease [1] which happens when the arteries in the extremities get blocked on and off which results in inflammation. The episodes of pain are triggered or aggravated by pressure, heat, exertion and stress and these attacks are periodic.
The intense burning pain can lead to impairment of functioning in daily routine. Individuals with this disorder have to adjust to avoid exacerbation of the symptoms. The cause remains unclear, but five percent of cases with erythromelalgia have an inherited tendency which demonstrates the role of genetic mutations in the etiology of this disorder. Diagnosis is mainly clinical with few tests for detection of causes. The treatment is mainly rest, elevating the affected extremity, avoiding heat or warmth, and local application of cold. Relief with cold is a characteristic sign of patients with erythromelalgia. Many medications are available which provide a certain level of relief, thus no single medication can be advised. Many over-the-counter pain relief drugs, anticonvulsants and antidepressants have been tried which help the patients to some extent. Thus, a combination of medications is given to help the patient in an effective manner. In any case, being a progressive condition, it not properly treated this chronic disorder  can hamper the quality.

Erythromelalgia is a rare vascular disorder associated with an increased blood flow to hands and legs resulting in severe redness, warmth and burning sensation. It happens due to some abnormality in the blood flow and nervous system. This abnormality is not clearly understood, so no exact cause for this disorder is known. This usually can also have an adult or late onset, at around 50-60 years which is a very common form. It can also have an early age onset in the pediatric group. Erythromelalgia can be of two types, primary and secondary, based on the presence of some underlying blood disorder such as increased production of blood cells like platelets. Primary form of erythromelalgia has no underlying medical cause.
The characteristic symptom of this condition is unbearable burning pain, warmth and severe redness of limbs, which is relieved only by cool application and elevation of the limb. It usually affects both upper and lower extremities. Warmth and heat aggravate and trigger the episodes of pain. This is a chronic, remitting disorder with recurrent attacks.
The treatment options are variable and every individual shows a different response. A diagnosis is made on physical examination, and certain blood tests may be done to detect the underlying blood disorder. No definite diagnostic test is available. Treatment is usually with oral medications such as aspirin, anti –inflammatory drugs, painkillers and combination of medications. Dosages are increased gradually depending on patient's response. Other general preventive measures should be followed such as avoidance of warmth, heat and vigorous exercises. This condition is treatable, but every individual shows a different response.

1. Drenth JP, van Genderen PJ, Michiels JJ. Thrombocythemic erythromelalgia, primary erythermalgia, and secondary erythermalgia: three distinct clinicopathologic entities. Angiology. 1994 Jun;45(6):451-3.
2. Michiels JJ, Drenth JP, Van Genderen PJ. Classification and diagnosis of erythromelalgia and erythermalgia. Int J Dermatol. Feb 1995;34(2):97-100.
3. Han C, Dib-Hajj SD, Lin Z, Li Y, et al. Early- and late-onset inherited erythromelalgia: genotype-phenotype correlation. Brain. Jul 2009;132(Pt 7):1711-22.
4. Davis MD, O'Fallon WM, Rogers RS 3rd, Rooke TW. Natural history of erythromelalgia: presentation and outcome in 168 patients. Arch Dermatol. Mar 2000;136(3):330-6.
5. Charkoudian N. Skin blood flow in adult human thermoregulation: how it works, when it does not, and why. Mayo Clin Proc. May 2003;78(5):603-12.
6. Waxman SG, Dib-Hajj SD. Erythromelalgia: a hereditary pain syndrome enters the molecular era. Ann Neurol. Jun 2005;57(6):785-8.
7. Michiels JJ, Abels J, Steketee J, et al. Erythromelalgia caused by platelet-mediated arteriolar inflammation and thrombosis in thrombocythemia. Ann Intern Med. Apr 1985;102(4):466-71.
8. Orstavik K, Weidner C, Schmidt R, et al. Pathological C-fibers in patients with a chronic painful condition. Brain. Mar 2003;126(Pt 3):567-78.
9. Mork C, Kalgaard OM, Kvernebo K. Impaired neurogenic control of skin perfusion in erythromelalgia. J Invest Dermatol. Apr 2002;118(4):699-703.
10. Moody S, Pacheco S, Butler IJ, Koenig MK. Secondary Erythromelalgia Successfully Treated With Intravenous Immunoglobulin. J Child Neurol. 2012 Jul;27(7):922-3.