PS35 A sutured thermoplastic facial mask for severe refractory trigeminal trophic syndrome

Abstract

Trigeminal trophic syndrome is a rare neuropathic condition characterized by facial dysaesthesia, ulceration and compulsive self-manipulation following trigeminal nerve injury. It most commonly occurs after herpes zoster ophthalmicus and is frequently refractory to conventional medical and topical therapies. Ongoing self-trauma can result in significant tissue destruction and morbidity. We describe a novel multidisciplinary mechanical intervention for severe, treatment-refractory trigeminal trophic syndrome. A man with idiopathic Parkinson disease was referred for dermatology assessment with extensive ulceration in a right trigeminal nerve distribution following herpes zoster ophthalmicus. He reported persistent neuropathic pain, pruritus and dysaesthesia, leading to repetitive excoriation and destruction of the right nasal ala. A diagnosis of trigeminal trophic syndrome was made. Previous management included gabapentin, pregabalin, topical wound care and multiple occlusive dressings, but without sustained benefit, as dressings were repeatedly removed. N-Acetylcysteine 600 mg twice daily was commenced in conjunction with gabapentin. In view of ongoing deterioration, a customized thermoplastic facial mask was designed by a radiation oncologist and surgically sutured in place by the plastic surgery team to occlude the affected area and prevent further manipulation. The patient tolerated the device well and remained compliant with its use, including wearing gloves overnight to minimize interference. Over 6 weeks of occlusion, there was marked improvement in ulceration with progressive re-epithelialization and no further excoriation. On removal of the mask, significant clinical improvement was observed, although complete resolution had not yet been achieved. No device-related complications occurred. In severe, refractory trigeminal trophic syndrome, a sutured thermoplastic facial mask can provide an effective and well-tolerated mechanical adjunct to pharmacological therapy. This multidisciplinary approach may limit self-injury and facilitate meaningful clinical improvement when conventional measures have failed.