Notalgia Paresthetica ( NP)

by

NOTALGIA PARESTHETICA( NP)
At a Glance

  • sensory neuropathic syndrome of the back skin
  • may include localized burning, pain, tenderness, hyperalgesia, or dysesthesiason a small patch of the mid back
  • associated with a poorly circumscribed tan or hyperpigmented patch
  • chronic condition
  • causes discomfort and nuisance to affected patients
  • not life threatening
  • common disorder which remains largely underdiagnosed
  • no uniformly effective treatment available
     

Synonyms, Key Words, and Related Terms
 

Notalgia paresthetica, NP, Notalgia, sensory disturbance of the back, unilateral itching of back, interscapular itching, skin dysesthesia of back, localized pruritus syndrome, sensory neuropathic syndrome, hyperalgesia, unilateral back itching, nostalgia, nostalgia paresthtica, notalgia paresthetic, what is notalgia, nostalgia paresthetica, photos of notalgia, pictures of notalgia parsthetica, best treatment for notlagia, Specialist for notalgia, back itching, bra allergy, back rash, TENS, Transcutaneous electrical nerve stimulator

 

 

 

Abstract

 

Notalgia paresthetica (NP) is a common, refractory sensory neuropathic syndrome with the hallmark symptom of localized pruritus of the unilateral infrascapula. It is generally a chronic, non-curable condition with periodic remissions and exacerbations. While the dermatologic syndrome may be multi-factorial in etiology, its possible association with underlying cervical spine disease needs to be evaluated for proper treatment. Radiographic studies of the spine may be more considered than they are currently. Collaborative multi-specialty evaluation by dermatology, radiology, neurology, and orthopedics may be indicated in primary management of this condition. First line therapy for notalgia paresthetica with associated cervical disease may include non-dermatologic spinal treatments such as spinal manipulation, physical therapy, massage, cervical traction, cervical muscle strengthening, and oral non-steroidal anti-inflammatory medications and muscle relaxants. Notalgia paresthetica may in fact be a dermatologic sign of an underlying systemic disease.

Case Report


37 year old patient presented with 3 years of intermittent bouts of recurrent itching on the right infrascapular skin of the back in T5-T6 dermatome. Failed past Notalgia Paresthetica skin treatments had included topical clobetasol cream, fluocinonide cream, oral hydroxyzine, oral diphenhydramine, chlortrimeton, intralesional triamcinolone 2.5mg/cc, and Tiger balm.


MRI of the cervical and thoracic spine revealed C5- C6, and C6-C7 disc protrusions and multiple osteophytes at these levels.

Discussion


Notalgia paresthetica (NP) is a sensory neuropathic syndrome of the back, classically of the unilateral infrascapula. It is primarily associated with intense localized pruritus. NP was first named in 1934 and described as episodic itching or pain on a small patch of the mid back, usually an area of skin just past easy reach.


Additional features of the dermatologic condition may include localized burning, pain, tenderness, hyperalgesia, or dysesthesias.  Notalgia paresthetica may be associated with a poorly circumscribed tan or hyperpigmented patch in the symptomatic area. Notalgia paresthetica tends to be a chronic condition with periodic remissions and exacerbations. While not life threatening and not generally associated with other co-morbidities, it does frequently decrease quality of life causing much discomfort and nuisance to the affected patients.


Treatment with topical modalities have generally failed and are difficult because of the difficult to reach location. To date, there has been no clearly described etiology and no uniformly effective treatment for notalgia paresthetica.


Although the etiology of notalgia paresthetica is unclear, two of the multiple proposed possible mechanisms include 1) localized increased sensory innervation of the affected skin areas and 2) neuropathy from degenerative cervico-thoracic disc disease or direct nerve impingement.

A study by Savk et al in 2000 studying 10 patients with NP demonstrated normal neurological examination and standard electrodiagnostic results in all study patients. All had skin histopathology compatible with post inflammatory hyperpigmentation. There were no amyloid deposits or other described pathology on pathologic exam of the skin. Seven of the 10 cases confirmed radiographic changes in the vertebrae corresponding to the dermatome of the cutaneous lesion. 9

An earlier study by Springer et al in 1990 evaluating the mechanism of notalgia paresthetica studied whether the cutaneous symptoms were caused by alternations on the cutaneous innervation of the involved infrascapular area. They postulated that the histology findings with increased dermal innervation to the areas however no measurable change in the distribution of neuropeptide-immunoreactive axons was found. There was an increase in the number of intradermal PGP 9.5-immunoreactive nerve fibers and epidermal dendritic cells compared with unaffected areas from the same patients and normal controls. It was concluded that the symptoms of NP may in part be related to an increase in the sensory epidermal innervation in the affected skin areas. 3

Histologic studies have shown cutaneous changes in a few cases including lichen amyloid which may be secondary to the localized chronic scratching and rubbing. 12

Clinical observations in orthopedics has established a clear relationship between the upper thoracic/interscapular region and the lower cervical spine. Frequently, cervical disc disease presents as referred pain in the upper thoracic and interscapular area. Similarly, some tumors of the cervical medulla have also presented as interscapular pain. 2

Some have speculated direct involvement and actual entrapment of the posterior rami of T2 to T6 spinal nerves. However, there is referred symptoms from the cervical area directly to the infrascapular back. Degenerative vertebral and disc changes corresponding to the affected dermatome may be observed in some cases. Recent literature supports a role for radiographic imagine of cervical and thoracic spine to exclude disc disease and possible nerve compromise.

With recent advances in radiography and availability of magnetic resonance imaging (MRI), earlier detection and intervention of cervical disc disease may be possible. Early recognition may promote timely intervention and treatment to prevent cervical spine disease progression. In addition to degenerative cervical discs, osteoarthritis, and cervical spine strain and muscle spasm, there may be a neoplasm or other pathology of the cervical spine contributing to notalgia paresthetica.

There is some thought that there may be a relation between notalgia paresthetica and brachioradial pruritus. The recently described association of many cases of brachioradial pruritus (BRP) and cervical spine disease and description of the disease as a possible neuropathic/ neurogenic condition also support a probable neuropathic association of nostalgia paresthetica. 5 In contrast, notalgia paresthetica is unilateral while BRP may be involving unilateral or bilateral upper extremities.

Topical therapies aimed at the back may be in fact be ineffectual or partially effective as basic emollients. Since the disease does have periodic spontaneous remissions and exacerbations, it may be difficult to accurately measure response to various therapies. A placebo response may be considered with some therapies.

The differential diagnosis in notalgia paresthetica may include allergic or irritant contact dermatitis, fixed drug eruption, dermatophytosis, neoplasm, lichen amyloid, arthropod reaction, lichen simplex chronicus, neurodermatitis, infection, other hypersensitivity reaction.

During the initial assessment of patients with notalgia paresthetica, it is important to obtain a thorough past history of osteoarthritis, prior neck trauma, motor vehicle accident, vertebral fracture, cervical neoplasm or malignancy, or cervical disc disease. In the absence of positive medical history, radiographs or MRI of the cervical spine may aid in diagnosis and treatment. Further, a positive family history of osteoarthritis or vertebral disc disease may be contributory.

When pruritus is generalized and persistent, a full laboratory workup including complete blood count, chemistry panel including renal and liver functions, chest x-ray, and other studies may be warranted to exclude other causes.

Proper management of notalgia paresthetica may involve a multi-specialty cooperative effort of dermatology with radiology, orthopedic surgery, neurology, and adjunctive fields including acupuncture, chiropractic, and physical therapy.

While to date there has been no uniformly effective treatment, current therapeutic options for notalgia paresthetica include capsaicin cream, eutectic mixture of local anesthetic (EMLA) cream, topical steroids, pramoxine cream, topical cooling, oral steroids, Tiger balm, menthol creams, Cordran tape, intralesional corticosteroid injections, botulinum toxin injections, 11 oral antihistamines, hydroxyzine, doxepin, topamax, anticonvulsant medications, carbamazepine (Tegretol) antidepressant medications, gabapentin (Neurontin), oxcarbazepine, 14 topiramate, thalidomide ,10 paravertebral local anesthetic block, 15 cervical epidural injection, surgical resection of the rib, and many others. Some of the current systemic therapies may in fact exert their effect through the spinal nerves and central nervous system thereby supporting the neuropathic etiology of NP.

In the future, first line therapy for notalgia paresthetica with associated cervical disease may include non-dermatologic, TENS or transcutaneous electrical nerve stimulation, non-invasive treatments such as spinal manipulation, physical therapy, cervical soft collars, massage, cervical traction, cervical muscle strengthening and increased range on motion, cervical discectomy with fusion, oral non-steroidal anti-inflammatory medications (ibuprofen, celecoxib, ketoralac) and oral muscle relaxants (carisoprodal, cyclobenzapril, methocarbamol, metaxalone). Other measures for degenerative disc disease as introduced may also be considered.


Conclusions

Notalgia paresthetica may not be solely a skin disease per se but a cutaneous sign of an underlying degenerative cervical spine disease. The striking association of notalgia paresthetica with degenerative or traumatic cervico-thoracic spine disease suggests that early spinal nerve impingement may contribute to the pathogenesis of this skin symptoms of the disease. Additional studies are needed to further assess the relationship of notalgia paresthetica with cervical spine disease. Whether this is a causal or coincidental finding remains to be determined in larger studies. While topical therapies may in some cases seemingly help decrease the localized symptoms in notalgia paresthetica, systemic or broader scope spinal evaluation may be warranted to fully evaluate refractory cases. Cervical spinal imaging and treatment may be appropriate as primary or first line therapy in many cases of notalgia paresthetica.

  

Article by
Orange County Dermatologist