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ActaDV ActaDV
Advances in dermatology and venereology Acta Dermato-Venereologica
Successful Treatment of Epidermal Nevus-associated Pruritus with Topical Ketamine – Amitriptyline – Lidocaine
Jose A . JALLER and Gil YOSIPOVITCH * Department of Dermatology & Cutaneous Surgery , University of Miami Miller School of Medicine , 1600 NW 10th Avenue , RMSB 2023A , Miami , FL , 33136 , USA . * E-mail : gyosipovitch @ med . miami . edu Accepted Oct 2 , 2017 ; Epub ahead of pint Oct 3 , 2017
Inflammatory linear verrucous epidermal nevus ( ILVEN ) is a rare , linear , unilateral , pruritic eruption that usually presents during childhood . It is more commonly seen on an extremity , although cases on the head and neck area have been reported in the past ( 1 ). It is considered a variant of keratinocytic epidermal nevus ; however , it has a significant histological similarity with psoriasis . Patients who have this condition usually complain of intense pruritus ( 2 ). Treatments that are regularly effective in psoriasis have shown low efficacy on the management of these lesions , as well as their related symptoms ( 3 ). We present here a case of successful treatment of pruritus associated with an epidermal nevus with the use of topical Ketamine 10 % – Amitriptyline 5 % – Lidocaine 5 % in lipoderm base ( TKAL ). The preparation is widely used in the US for nociceptive pain and is prepared by a compounding pharmacy . All ingredients are FDA approved .
CASE REPORT
A 24-year-old man presented to our Itch Clinic complaining of an extremely pruritic plaque involving his forehead and temple area , compatible with a diagnosis of ILVEN . The patient had this lesion since childhood , initially intermittently itching , however , over the past few years it became severely pruritic . He stated that itching was 9.5 / 10 in the itch Numeric Rating Scale ( NRS ; ( 4 )), lasted several hours , presented 3 – 4 times a week , and was predominantly at bedtime , interfering with his sleeping pattern . Topical therapies including mid and high potency steroid ointments and multiple moisturizer creams had failed to relieve his symptoms . The past medical history and family history were insignificant otherwise . Cutaneous examination revealed a well-demarcated , linear , red , scaly plaque on his right forehead ( Fig . 1 ), as well as multiple linear verrucous papules on his neck that were coalescing into a plaque . A biopsy of the forehead lesion was consistent with a psoriasiform epidermal hyperplasia with spongiosis and moderate inflammation , compatible with epidermal nevus with secondary inflammation . At that point , we decided to start him on TKAL applied on the lesions 1 – 3 times daily . After only one application , the patient noted significant improvement of his itch that lasted for more than 6 h . After 6 weeks of treatment , the patient returned to our clinic with complete relief of his pruritus and an itch rating of 0 / 10 on the itch NRS , and
Fig . 1 . Well-demarcated , linear , red , scaly plaque on the right forehead consistent with ILVEN ( post-treatment ).
noted no side effects . In addition , there was significant reduction of the erythema and hyperkeratosis .
DISCUSSION
To our knowledge , this is the first time that TKAL has been used to treat pruritus associated with epidermal nevi . We recently published a retrospective analysis that demonstrated the effectiveness of TKAL on chronic itch associated with different skin disorders ( 5 ). This analysis included 96 patients ; noted side effects included mild burning sensation and redness in the application site . Only one patient reported dizziness but was able to continue with the therapy . Nonetheless , blinded controlled clinical studies are required to further evaluate TKAL ’ s safety and utility ( 5 ). Since the lesions in our patient were limited to head and neck area where cutaneous penetration of drug is high , the effectiveness of this topical compound might have been favored . It is unclear if one compound is superior to the others or if the combination
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2018 Acta Dermato-Venereologica . doi : 10.2340 / 00015555-2811 Acta Derm Venereol 2018 ; 98 : 121 – 122