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Notalgia paresthetica
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Notalgia paresthetica is a unilateral sensory neuropathy characterized by pruritus, tingling, burning pain, or hyperesthesia to light touch at the medial border of the scapula. Accompanying pigmentation or mild lichenification is secondary to scratching. Occasionally the distribution may be bilateral, and a few hereditary cases have been described. Pruritus is believed to result from nerve impingement or chronic nerve trauma and often persists for years.
Management Strategy
Treatment aims to reduce the itch by altering peripheral or central nerve transmission. Topical corticosteroids are generally ineffective unless secondary inflammation is present.
Topical capsaicin 0.025% two times daily for 6 weeks depletes sensory nerve transmitters in the skin. In case of relapse, the treatment may be repeated for a few days or weeks until pruritus subsides. Capsaicin may be applied in higher concentrations, such as 0.075% or 0.1%; with increasing concentrations there is more burning, but the desensitization of the skin occurs sooner. High-dose (8%) capsaicin patch for 1 hour is associated with severe burning. It has shown considerable variability in efficacy, reducing pruritus for 2 days to 3 months.
Topical tacrolimus 0.1% twice daily for 6 weeks has reduced incidence of side effects and may be tried in less severe cases.
Local anesthesia with 5% lidocaine patch twice daily blocks peripheral nerve transmission, but there is a risk for contact allergy to the anesthetic.
Daily electrical stimulation for 20 min using CFS or transcutaneous electrical nerve stimulation (TENS) for 2–5 weeks has been tried with good results, with the pruritus relapsing gradually.
Deep intramuscular acupuncture to the paravertebral muscles in the T2–T6 dermatome once a week until the pruritus subsides, as well as spinal physiotherapy, has been reported in a few cases.
Despite several promising case reports on single treatments with botulinum toxin , a randomized clinical trial on 20 patients could not confirm the efficacy.
Anesthetic paravertebral block has been described in anecdotal case reports. The reduction of itch due to this treatment may last for months or years.
Oral therapy may be preferred in patients in whom repeated topical treatments may be difficult to perform. Anticonvulsants such as gabapentin or oxcarbazepine alter central nerve transmission. Low dose gabapentin (100–900 mg daily) or oxcarbazepine (600 mg daily) is often sufficient.
Most of these treatments offer only transient relief, and there is a considerable risk of relapse upon discontinuation of treatment.
Specific Investigations
Notalgia paresthetica. Case reports and histologic appraisal
Weber PJ, Poulos EG. J Am Acad Dermatol 1988; 18: 25–30.
Skin biopsies from 14 patients revealed necrotic keratinocytes. Melanin and melanophages in the upper and mid-dermis were found in biopsies of patients with pigmented lesions.
Symptoms of notalgia paresthetica may be explained by increased dermal innervation
Springall DR, Karanth SS, Kirkham N, et al. J Invest Dermatol 1991; 97(3): 555–61.
Skin biopsies using immunohistochemistry revealed a significant increase of sensory nerve fibers (PGP 9.5) in the dermis of five patients with notalgia paresthetica compared with the contralateral unaffected area and with 10 healthy controls.
Investigation of spinal pathology in notalgia paresthetica
Savk O, Savk E. J Am Acad Dermatol 2005; 52: 1085–7.
Forty-three patients with notalgia paresthetica underwent radiography of the spine. Thirty-seven skin lesions were accompanied by relevant degenerative spinal changes (60.7%).
Notalgia paresthetica associated with nerve root impingement
Eisenberg E, Barmeir E, Bergman R. J Am Acad Dermatol 1997; 37: 998–1000.
An impingement of the nerve root was confirmed by MRI in one patient.
Notalgia paresthetica is a clinical diagnosis, and none of the previously mentioned investigations are required in the clinical situation.
Successful treatment of notalgia paresthetica with topical capsaicin: vehicle-controlled, double-blind, crossover study
Wallengren J, Klinker M. J Am Acad Dermatol 1995; 32: 287–9.
This double-blind crossover comparison between capsaicin 0.025% and vehicle cream was performed in 20 patients for 10 weeks, with the 4-week treatments being followed by 2 weeks of washout. The group treated with capsaicin first had a reduction of VAS (visual analog scale) from 61% to 35% during the first period, whereas in the other group, VAS was reduced from 52% to 27%. Most patients relapsed within a month.
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