eMedicine Specialties > Dermatology > Diseases of the Subcutaneous Tissue
Adiposis Dolorosa: Treatment & Medication
Updated: May 15, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Traditional management of Dercum disease (adiposis dolorosa) has been largely unsatisfactory relying on weight reduction and surgical excision of particularly troublesome lesions. Even at the present time, no known drug can change the course of the disease, and available treatments are only symptomatic.
Nonpharmacological approaches for Dercum disease (adiposis dolorosa) may be used as adjuncts to pharmacologic treatments. Some of these include acupuncture, cognitive behavioral therapy, hypnosis, and biofeedback.17
The pharmacological treatments include the following:
- Corticosteroids: Prednisone, 20 mg daily, has been reported to provide some pain relief.2 However, in one case, the induction of disease was associated with high-dose corticosteroids.4
- Anesthetics: Intravenous lidocaine, 400 mg over 15 minutes every other day, has been reported to provide pain relief for 10 hours to several months.18,19 The exact mechanism of action is uncertain and remains to be elucidated as to whether it is a central effect or due to its effect on blood flow. Long-term intravenous lidocaine therapy has been associated with neurotoxicity.
- Analgesics: Traditional analgesics, such as nonsteroidal anti-inflammatory drugs, have a poor effect. The lipomas are unresponsive to analgesics, and paracetamol and dextropropoxyphene are the first choices. Localized pain may sometimes be treated with a cortisone/anesthetic injection, alternatively with sterile water given intracutaneously or more deeply.
- Others medications
- Because of troublesome swelling of the fingers, some patients may require diuretics.
- In 2 reported cases of Dercum disease (adiposis dolorosa), interferon (INF) alfa-2b induced long-term relief of pain in 2 patients with adiposis dolorosa and chronic hepatitis C. The analgesic effect of IFN therapy was unexpected and occurred 3 weeks after treatment with 3 million units, 3 times per week, for 6 months. Whether the mechanism of pain relief with IFN is related to its antiviral effect, to the production of endogenous substances (eg, endorphins produced by IFN), or to the interference of INF with interleukin 1 and tumor necrosis factor-alpha cytokine production, which are involved in cutaneous hyperalgesias, remains unclear.20
- Two Dercum disease (adiposis dolorosa) case reports have described pain relief with daily intake of oral mexiletine, an antiarrhythmic.19,21
- Singal et al reported improvement of a patient's Dercum disease (adiposis dolorosa) while on infliximab, with and without methotrexate, for ankylosing spondylitis. The patient experienced recurrent weight gain and lipoma pain with discontinuation of these medications.22
- Desai et al reported on treatment with a lidocaine (5%) patch,23 and Lange et al reported on successful therapy with pregabalin with manual lymphatic drainage.24
Surgical Care
- Liposuction
- Liposuction is regarded as a supportive treatment for Dercum disease (adiposis dolorosa). Any skeletal pain is not affected. A significant initial reduction of pain and an improved quality of life is seen; these effects decrease over time.
- Liposuction is indicated for patients with general lower-body fat or more localized large deposits of fat at the knees, on the arms, on the thighs, or on the stomach as opposed to those with general diffuse pain. In those patients, liposuction is considered a risky operation, requiring about a week of care in the plastic surgery department.
- Surgical operation: Excision of isolated painful lipomas that are pressing and causing numbness and tingling, while not preventive, is useful in ameliorating local symptoms of pain.
Consultations
- Psychiatrist: Depression and other psychosomatic symptoms are associated with Dercum disease (adiposis dolorosa). Many patients find they are misjudged and require psychological support.
- Rheumatologist: A rheumatologic consultation is warranted to rule out osteoarthritis and fibromyalgia.
- Endocrinologist: An endocrinologic etiology, such as hypothyroidism and Cushing syndrome, should be ruled out.
Diet
Experience shows that lasting weight reduction by changing the diet is difficult to achieve and does not appreciably affect the pain.
Activity
Light physical activity may worsen symptoms because of the stiffness experienced after periods of rest and minimal activity. Patients should avoid monotonous, static work and physical and psychological stress.
Medication
Traditional management of Dercum disease (adiposis dolorosa) has been largely unsatisfactory relying on weight reduction and surgical excision of particularly troublesome lesions. Even at the present time, no known drug can change the course of the disease, and available treatments are only symptomatic. However, in 2 reported cases, INF alfa-2b induced long-term relief of pain in 2 patients with Dercum disease (adiposis dolorosa) and chronic hepatitis C (see Medical Care).
Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.
Prednisone (Meticorten, Orasone, Deltasone, Sterapred)
May provide pain relief. Caution because the adverse effects may outweigh the benefits. Immunosuppressant for treatment of autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Stabilizes lysosomal membranes and also suppresses lymphocyte and antibody production.
Adult
20 mg PO qd; taper over several wk as condition improves
Pediatric
Not established
Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, fungal, connective tissue, or tubercular skin infections; peptic ulcer disease; hepatic dysfunction; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Anesthetics
Lidocaine is reported to provide pain relief for 10 hours to several months.18,19 The exact mechanism of action is uncertain, and whether it is a central effect or due to its effect on blood flow remains to be elucidated. Cardiac monitoring is required. This should be considered an investigational therapy.
Lidocaine (Dilocaine, Xylocaine)
Decreases permeability to sodium ions in neuronal membranes. Results in inhibition of depolarization, blocking transmission of nerve impulses.
Adult
400 mg IV over 15 min qod
Pediatric
Not established
Coadministration with cimetidine or beta-blockers increases toxicity; coadministration with procainamide and tocainide may result in additive cardiodepressant action; may increase effects of succinylcholine
Documented hypersensitivity to amide-type local anesthetics; avoid in Adams-Stokes syndrome and Wolf-Parkinson-White syndrome; avoid in severe sinoatrial, AV, or intraventricular block, if artificial pacemaker not in place
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use a solution without preservatives; caution in heart failure, hepatic disease, hypoxia, hypovolemia or shock, respiratory depression, and bradycardia; may increase risk of CNS and cardiac adverse effects in elderly patients; high plasma concentrations may cause seizures, heart block, and AV conduction abnormalities
Analgesics
Pain control is essential for quality patient care, and it ensures patient comfort.
Acetaminophen (Feverall, Tempra, Aspirin Free Anacin, Tylenol)
Drug of choice for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI tract disease, or who are taking oral anticoagulants.
Adult
650 mg PO q6h
Pediatric
Not established
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose
Propoxyphene (Darvocet)
Drug indicated for mild to moderate pain.
Adult
65 mg PO q4h; not to exceed 390 mg/d
Pediatric
Not available
May increase serum concentrations of MAOIs, tricyclic antidepressants, carbamazepine, phenobarbital, and warfarin
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates, substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction, schedule IV narcotics
More on Adiposis Dolorosa |
| Overview: Adiposis Dolorosa |
| Differential Diagnoses & Workup: Adiposis Dolorosa |
 Treatment & Medication: Adiposis Dolorosa |
| Follow-up: Adiposis Dolorosa |
| References |
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References
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Further Reading
Keywords
adiposis dolorosa, Dercum's disease, Dercum disease, painful lipoma, fatty tissue rheumatism, juxta-articular adiposis dolorosa (occurs around the knees)
