Atypical Facial Pain

presented by

David Elpern M.D., Williamstown, MA, USA

on September 30, 2004

Dermatologist, The Skin Clinic, Williamstown, MA, USA

L.D., 40-year-old computer technician
7 years

L.D. presented in 1999 with a two year history of painful area just above the medial aspect of the right eyebrow for the past seven years. He has a history of cystic acne. In the past, he had recurrent episodes of acute swelling in this area and was seen in the emergency room where he received intravenous antibiotics (but no cultures were done). The pain has persisted, but only some of the swelling remains. He describes the pain as follows: “It is almost constant with a feeling as if there is a cyst deep under the skin. It seems to be aggravated by touch, heat and sweat. The pain and swelling also occur for no apparent reason at all and to varying degrees. It is accompanied by swelling and redness of the entire orbital area and sometimes down the side of the right cheek. There are also periods of time where my entire face feels and looks as if it has been sunburned. There is also itching and burning above the right eye. The pain, swelling, and redness occur simultaneously. The problem doesn't seem to be getting any better and is seriously affecting my quality of life.”

Over the years, he has seen four dermatologists, two ENTs, two neurologists, his primary care physician and an acupuncturist. He has been treated with minocycline, isotretinoin, prednisone, and amytriptylene. The isotretinoin cleared his cyctic acne, but the pain and swelling remain. He has periods of depression related to the pain, but is gainfully employed and has a stable marital and family relationship.

Physical Examination

At present, mild swelling of right forehead above medial brow. I have witnessed the erythema and mild scaling on occasion. Before isotretinoin, the swelling above the right eyebrow was more pronounced and more erythematous. There are some ice-pick scars in other areas of face.


Laboratory Data

Lab: all blood studies normal, CTs and MRIs nl. Areas cultured have always been sterile or normal flora.


Idiopathic Atypical Facial Pain

Reasons Presented

L.D. has persistent facial pain which is depressing and discouraging. No physician has been able to help him with this. We are looking for diagnostic and therapeutic suggestions.

Questions and Discussions

This is a 40 yo man with a seven year of “atypical facial pain.” This began in the setting a cystic acne and I postulate that the pain is related to scarring and/or fibrosis from a cyst in the affected area, but have not found any supporting literature and the neurologists he has seen do not have a pathological diagnosis. The patient it left with uncontrolled pain. Alternatively, could there be a subgaleal cyst in this area causing the pain. ENT surgeons have been reluctant to explore this area.

  1. Burchiel K A new classification for facial pain. J.Neurosurgery. 2003 Nov;53(5):1164-6; discussion 1166-7. (To view abstract)
  2. Graff-Radford SB. Facial pain. Curr Opin Neurol. 2000 Jun;13(3):291-6. (To view abstract)
Comments from Faculty and Members

Professor Camillo Di Cicco M.D., Professor of Dermatology, University of Rome, Italy on Sept 30, 2004

Pain following "Zoster sine materia".
Tegretol ( carbamazepin)

Stephen Glinick M.D., Providence, RI, USA on Sept 30, 2004

I do not know what this unfortunate patient has. However the lesion is sitting right on top of the supraorbital nerves and I suspect an entrapment or compression phenomenon. Have nerve conduction studies been done? Has capsaicin been tried? Neurontin? If neuropathy is suspected then I wonder if cautious exploration by a head and neck surgeon might free up the nerve.

Caroline Koblenzer M.D., Professor of Dermatology and Psychiatry, University of Pennsylvania, Philadelphia, PA, USA on October 1, 2004

This unfortunate man's history,trekking from doctor to doctor, in a variety of specialties, in the course of a long and fruitless search for relief, is entirely typical of those with cutaneous dysesthesia. In this case there was objective evidence of pathology, which is quite unusual, in my experience.

From the report, I understand that MRI and CT scans were unrevealing. Would ultrasound be helpful ? I understand that it does a good job in soft tissue. Also, perhaps a biopsy at a time when erythema is evident ?

Unfortunately the treatment of unexplained dysesthesia tends to be a matter of trial and error, but I have found both carbamazepine and gabapentine effective in some cases. I have also considered that it may represent a type of tactile halucination, and on that basis have used anti-psychotics, particularly pimozide, again with some success. There is also the possibility that in some cases dysesthesia may be a somatic expression of depression, and I have had some success also with the SSRI's. I look forward to a follow-up.

Benjamin Barankin MD, Department of Dermatology, University of Alberta, Edmonton, Canada on October 1, 2004

I would consider trying one of the anti-epileptics. A no-promises trial of BOTOX might be beneficial. He may benefit from anti-depressants for what sounds like a reactive depression to his longstanding condition.

Joel Schlessinger M.D., Omaha, NE, USA on October 1, 2004

I would try a prophylactic course of valacyclovir. Although herpes may not be the main pathology here, it deserves to be ruled out as a provocateur.

Donald Huldin M.D., Kalamazoo, MI, USA on October 4, 2004

DX---post herpetic neuralga RX Trial Bcomplex 2cc IM q 3 weeks X 6..Avoid all stimulents!!! esp caffeine

Richard Sontheimer M.D., Professor of Dermatology, University of Iowa Carver College of Medicine, Iowa City, IA, USA on October 7, 2004

I asked a senior neurology resident at the Uiniv. of Iowa Hospitals and Clinics who is a personal associate of mine for her opinion on this case. Her answer was:
"In regards to the case, I agree that there likely is neural injury causing the pain. I think that while scarring and fibrosis of the nerve may have been the cause, the recurrent redness and swelling didn't really fit with that. Other possibilities include an underlying neuroma or other benign neural tumor of the opthalmic division of the trigeminal nerve. From my experience, cases like this almost always have a prominent psychological componenent. As work-up however, I would suggested the possibility of an ultrasound and a HR MRI with a 3 tesla unit which should be able to pick up even small abnormalities in the hands of an experienced radiologist. The suggestions for pain control all seemed reasonable, neurontin, tegretol and TCAs. I end up sending most of my similar cases to the pain clinic. They usually start narcotics."


Please Click Here To Comment and Evaluate

Back to September 17, 2004 Case