Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 19/03/2015
This article have been viewed 1794 times
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
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.
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.
Skin biopsy
Radiography of the thoracic spine
MRI of the thoracic spine
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 brown lesions.
Savk O, Savk E. J Am Acad Dermatol 2005; 52: 1085–7.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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