Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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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.
Forty-three patients with notalgia paresthetica underwent radiography of the spine. Thirty-seven skin lesions were accompanied by relevant spinal changes (60.7%).
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 above-mentioned investigations are required in the clinical situation.
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, the 4-week treatments being followed by 2 weeks of washout. The group treated with capsaicin first had a reduction of VAS 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.
Layton AM, Cotterill JA. Clin Exp Dermatol 1991; 16: 197–8.
All three patients improved upon treatment with 2.5% lidocaine and 2.5% prilocaine; two patients relapsed, but pruritus was reduced.
Wallengren J, Sundler F. Arch Dermatol 2001; 137: 1323–5.
Seventeen patients with different disorders of neuropathic pruritus completed the study. Four of five patients with notalgia paresthetica improved after daily use of CFS for 5 weeks, VAS being reduced from 65% to 40%. Itch gradually relapsed after the discontinuation of CFS.
Savk E, Savk O, Sendur F. J Dermatol 2007; 34: 315–19.
Nine of 15 patients treated with TENS for 2 weeks improved substantially, mean VAS being reduced from 100% to 45%.
Loosemore MP, Bordeaux JS, Bernhard JD. J Eur Acad Dermatol Venereol 2007; 21: 1440–1.
A case report on one patient who improved but relapsed upon discontinuation of treatment.
Savk E, Bolukbasi O, Akyol A, Karaman G. J Am Acad Dermatol 2001; 45: 630–2.
Four patients were treated with oxcarbazepin for 6 months: two improved, VAS being reduced from 80% to 50% and from 90% to 40%, respectively.
Raison-Peyron N, Meunier L, Acevedo M, Meynadier J. J Eur Acad Dermatol Venereol 1999; 12: 215–21.
Pruritus was reduced in four of six patients treated by spinal physiotherapy using ultrasound, or manipulation. The improvement was sustained for 1 to 9 years.
Wallengren J, Bartosik J. Br J Dermatol 2010; 163: 424–6.
Four patients with notalgia paresthetica received a total of 18–100 U of BTX-A to the affected area. Mean VAS was reduced by 40% at 6-week follow-up. At follow-up after 18 months pruritus relapsed.
Stellon A. Acupunct Med 2002; 20: 186–90.
Sixteen patients with different disorders of neuropathic pruritus completed the study. Four patients with notalgia paresthetica improved, mean VAS being reduced from 73% to 0%.
Goulden V, Toomey PJ, Highet AS. J Am Acad Dermatol 1998; 8: 114–16.
Paravertebral block at dermatome T3–T6 in one patient resulted in clearing of pruritus within a few days, lasting for 1 year of follow-up.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Capsaicin 0.025%
Lidocaine 5% patch
Cutaneous field stimulation
TENS
Gabapentin
Oxcarbazepine
Spinal physiotherapy with ultrasound and manipulation
Botulinum toxin A
Acupuncture (deep intramuscular stimulation) of the paravertebral muscles at T2–T6 once a week until pruritus subsides
Anesthetic paravertebral block at dermatome T3–T6 with bupivacaine 0.75% and methylprednisolone on one occasion
