Vol. 26 No. 3 September 2003 Journal of Pain and Symptom Management 785

Letters

Topical Capsaicin for SaphenousNeuralgia

To the Editor:We present an unusual cause of neuropathic

pain that was treated successfully with topicalcapsaicin.

Case ReportThe patient was an eighty-year-old man re-

ferred to our community palliative care teamfor symptom control in June 2001. He hadpreviously been admitted to a local hospital inApril 2000 for unstable angina. Coronary an-giography revealed triple vessel disease andhe was referred for coronary artery bypassgrafting. However, a lesion was noted on hischest radiograph and a CT of the chest wasperformed, which showed this to be a tumor.A CT guided biopsy confirmed non-small cellcarcinoma.

In June 2000, he underwent a triple coronaryartery bypass graft with saphenous vein graftsto the posterior descending, obtuse marginaland left anterior descending arteries. He re-ceived 6000 cGy radiotherapy in total to hislung lesion from August to December andwas doing well until June 2001 when he startedto become increasingly symptomatic.

He was seen at home by one of the authors.His main complaint was of burning pain downthe medial aspect of both calves. He hadbeen prescribed several analgesics, includingcarbamazepine, but these had been of no help.It became clear that adherence to his oral medi-cation regimen was somewhat haphazard, al-though he was applying various topical creamsreligiously. On examination, there was markedallodynia around the scars of his previous saphe-nous vein harvesting. There was no erythemaor signs of infection.

� 2003 U.S. Cancer Pain Relief CommitteePublished by Elsevier Inc. All rights reserved.

Further questioning revealed that the painhad been present since his bypass operation andit was the patient’s main concern.

As his adherence with creams seemed good,it was decided to try topical capsaicin five timesa day. He was advised to use gloves and warnedthat the pain may get worse before it got better.When he was seen a week later, the pain hadgone. His pain remained well controlled for twomonths with regular application of the creamwhen he was discharged from the service.

CommentSaphenous neuralgia is a recognized sequel

to vein harvesting for coronary artery bypassgrafting.1 It is a complex of symptoms that caninclude anesthesia, hyperesthesia and painwithin the distribution of the saphenous nerve.It is believed to be secondary to trauma to thisnerve and/or its branches, and intra-operativetechnique can alter the frequency of symp-toms.2,3 Although thought to be infrequent, arecent study showed that the incidence of anes-thesia may be as high as 72% at 20 months, butpain was only present in 3%.4 Various treat-ments have been tried, including local anestheticand steroid injections. Transcutaneous electri-cal nerve stimulation can have a role, and occa-sionally neurolysis or neurotomy has beenused.5 Like many neuropathic pains, the multi-plicity of approaches is indicative of the poorresponse to any one.

Capsaicin has been used in postherpetic neu-ralgia,6,7 painful diabetic neuropathy8and os-teoarthritis of the finger joints.9 Its benefitwas confirmed in a meta-analysis.8 It is believedto act by depleting primary afferent neurons ofpeptides, notably Substance P. Although capsa-icin has been used for saphenous nerve pain inanimal models,10 this is the first time it hasbeen used successfully in humans.

0885-3924/03/$–see front matter

786 Vol. 26 No. 3 September 2003Letters

Possible Exacerbation of AdrenalSuppression from IntrathecalMorphine in a Patient ReceivingPulsed Dexamethasone for MultipleMyeloma

To the Editor:The development of central hypogonadism

from intrathecally and orally administered opi-oids has been described recently.1–3 Althoughthe evidence suggests a high prevalence for cen-tral inhibition of gonadal function, evidencefor other forms of hormonal derangement fromchronic opioid use, viz., hypoadrenalism or hy-pothyroidism, is less clear. A recent study ofpatients receiving intrathecal opioids reporteda prevalence of adrenal suppression that was sig-nificantly higher than the general population.4

Adrenal suppression is a well-known effectof chronic steroid exposure and cessation ofsteroids is usually done by a gradual taper.5 Forpatients exposed to steroids on a short-termbasis, cessation may be done without the taper.One of the chemotherapeutic regimens for thetreatment of multiple myeloma involves theuse of thalidomide and pulsed dexametha-sone.6 Since the dexamethasone is given fora short period, no taper is generally instituted.The following case illustrates possibly in-creased adrenal suppression from intrathecalmorphine in a patient already receiving pulseddexamethasone for multiple myeloma.

Case ReportThe patient was a 61-year-old woman who

was diagnosed with multiple myeloma twomonths prior to her initial consultation withthe pain management service. For her multiplemyeloma, she had been started on thalido-mide 150 mg/day and dexamethasone 32 mgper oz. daily for 4 days followed by a breakfor 4 days. This cycle was repeated three timesfollowed by a 7-day break. A review of her medi-cal record showed she tolerated the chemother-apy very well except for complaints of mildfatigue during the treatment.

This case illustrates several key issues in pallia-tive medicine. First, we are often dealing withelderly patients who may have other concomi-tant disease. Second, a thorough past medicalhistory, pain history and physical examinationare essential in assessment. Third, we must beflexible in our treatment approach, respectingautonomy to maximize patient concordancewith medication.

Paul Perkins, MA (Hons) (Cantab), MB, BCh, MRCP(UK), Dip Pall Med

Sue Morgan, MB, BCh, BMedSci (Hons), Dip TherSusan P. Closs, FRCP, FRCPathTy Olwen Palliative Care ServiceMorriston HospitalSwansea NHS TrustSwansea, United Kingdom

doi:10.1016/S0885-3924(03)00280-X

References1. Lavee J, Schneiderman J, Yorav S, et al. Complica-

tions of saphenous vein harvesting following coro-nary artery bypass surgery. J Cardiovasc Surg 1989;30:989–991.

2. Pagni S, Ulfe EA, Montgomery WD, et al. Clinicalexperience with the video-assisted saphenectomyprocedure for coronary bypass operations. AnnThorac Surg 1998;66:1626–1631.

3. Nair NR, Griffiths G, Lawson RAM. Postoperativeneuralgia in the leg after saphenous vein coronaryartery bypass graft: a prospective study. Thorax 1988;43:41–43.

4. Mountney J, Wilkinson GAL. Saphenous neural-gia after coronary artery bypass grafting. Eur J Cardio-thorac Surg 1999;16:440–443.

5. Senegor M. Iatrogenic saphenous neuralgia: suc-cessful therapy with neuroma resection. Neurosur-gery 1991;28:295–298.

6. Bernstein JE, Korman NJ, Bickers DR, et al. Topi-cal capsaicin treatment of chronic post-herpetic neu-ralgia. J Am Acad Dermatol 1989;21:265–270.

7. Drake HF, Harris AJ, Gamester RE, et al. Ran-domised double-blind study of topical capsaicin fortreatment of postherpetic neuralgia. Pain 1990;5(S):S58.

8. Zhang WY, Wan Po AL. The effectiveness of topi-cally applied capsaicin: a meta-analysis. Eur J ClinPharmacol 1994;46:517–522.

9. McCarthy GM, McCarty DJ. Effect of topical cap-saicin in the therapy of painful osteoarthritis of thehands. J Rheumatol 1992;19:604–607.

10. Baranowski R, Lynn B, Pini A. The effects oflocally applied capsaicin on conduction in cutaneous

nerves in four mammalian species. Br J Pharmac1986;89:267–276.