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I would like to offer some comments on the excellent article by Sandroni and Davis¹ on topical transdermal amitriptyline and ketamine for severe erythromelalgia. From my own work with patients with erythromelalgia and as an erythromelalgia patient myself for the better part of 10 years, I am not surprised by the wide variation in response (0%-95% improvement) reported by the authors' 5 patients. Marked interindividual variation in therapeutic response occurs in patients with erythromelalgia.

The 2 patients with self-reported improvement of 95% and 90%, respectively, are particularly interesting. These patients experienced not only pain reduction but also unexpected improvement in the classic vascular symptoms of the disorder: flaring, redness, and heat intolerance. I am not aware that ketamine can produce these effects, so I suspect that the amitriptyline is responsible for these improvements. Amitriptyline enhances serotonin and norepinephrine, both of which are vasoactive. Indeed, drugs that enhance serotonin (sertraline) or . . . [Full Text of this Article]

AUTHOR INFORMATION
Jay S. Cohen, MD

RELATED ARTICLE

Combination Gel of 1% Amitriptyline and 0.5% Ketamine to Treat Refractory Erythromelalgia Pain: A New Treatment Option?
Paola Sandroni and Mark D. P. Davis
Arch Dermatol. 2006;142(3):283-286.
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