Background:
Erythromelalgia is a rare and debilitating condition characterized by episodic burning pain, erythema, and swelling, primarily affecting the extremities. Diagnosis is based on clinical history and the exclusion of differential diagnoses, as no confirmatory tests exist.

Case Presentation:
We report a 45-year-old male with a complex history of refractory pain for 4 years. His episodic pain predominantly affects the dorsum of the hands and feet, occasionally involving the face. The patient experiences burning sensations, erythema, and swelling episodes lasting up to two days, significantly impacting his quality of life. Chronic daily hip and ankle pain, from suspected avascular necrosis, further compound his condition. Despite extensive pharmacological and interventional treatments, including sympathetic blocks, dorsal root ganglion pulsed radiofrequency, and a lidocaine infusion, symptom relief remains limited.

Discussion:
It is unclear if the patient presents with primary or secondary erythromelalgia. Secondary is distinguished by asymmetrical distribution and association with systemic conditions such as hypertension and psoriasis. Genetic tests for mutations on SCN9A are pending, a cause of primary erythromelalgia. Management remains challenging due to the condition’s heterogeneous etiology and incomplete pathophysiological understanding. Lidocaine infusions, although not curative, offer the potential for symptom relief in refractory cases. Other reported cases have highlighted its role, often transitioning to mexiletine for maintenance therapy.

Conclusion:
The diagnostic complexity and therapeutic challenges of erythromelalgia highlight the need for individualized, multidisciplinary management strategies. Further research is warranted to optimize treatment protocols, including the role of lidocaine and other sodium channel blockers in refractory cases.