Notalgia paresthetica

Published on 19/03/2015 by admin

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[level-membership-for-dermatology-category]

Notalgia paresthetica

Joanna Wallengren

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Notalgia paresthetica is a unilateral sensory neuropathy characterized by pruritus or burning pain at the medial inferior tip of the scapula. Accompanying pigmentation or mild lichenification are 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.

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% three times daily for 5 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, licenced for intractable pain syndromes, should be used with restriction.

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 using cutaneous field stimulation (CFS) or TENS for 2 to 5 weeks has been tried with good results, 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. Also, single treatments with botulinum toxin or an anesthetic block have been described in anecdotal case reports. The reduction of itch due to these treatments 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 oxcarbazepin alter central nerve transmission.

Most of these treatments offer only transient relief and there is a considerable risk of relapse upon discontinuation of treatment.

Specific investigations

First-line therapies

imageCapsaicin 0.025% A
imageLidocaine 5% patch E

Second-line therapies

imageCutaneous field stimulation D
imageTENS D
imageGabapentin E
imageOxcarbazepine E

Third-line therapies

imageSpinal physiotherapy with ultrasound and manipulation D
imageBotulinum toxin A E
imageAcupuncture (deep intramuscular stimulation) of the paravertebral muscles at T2–T6 once a week until pruritus subsides E
imageAnesthetic paravertebral block at dermatome T3–T6 with bupivacaine 0.75% and methylprednisolone on one occasion E

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Notalgia paresthetica

Joanna Wallengren

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Notalgia paresthetica is a unilateral sensory neuropathy characterized by pruritus or burning pain at the medial inferior tip of the scapula. Accompanying pigmentation or mild lichenification are 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.

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% three times daily for 5 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, licenced for intractable pain syndromes, should be used with restriction.

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 using cutaneous field stimulation (CFS) or TENS for 2 to 5 weeks has been tried with good results, 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. Also, single treatments with botulinum toxin or an anesthetic block have been described in anecdotal case reports. The reduction of itch due to these treatments 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 oxcarbazepin alter central nerve transmission.

Most of these treatments offer only transient relief and there is a considerable risk of relapse upon discontinuation of treatment.