Neuropathic Itch of the Back: A Case of Notalgia Paresthetica

Abstract

Notalgia paresthetica refers to an isolated mononeuropathy involving chronic localized itch or paresthesia most often at the skin of the scapula or surrounding regions. There are no specific skin manifestations except those arising from chronic scratching and rubbing. The specific etiology remains unknown; however, it has been theorized that the neuropathic itch is caused by sensory nerve entrapment involving the posterior rami of the T2 to T6 nerve root. The entrapment is due to degenerative changes in the vertebrae. We report here a particular case of notalgia paresthetica in a 55-year-old woman. The patient visited our hospital for tingling pain around the left inferior angle of the scapula. Pruritus was first reported seven years ago with tingling pain developing only four months ago. There were no specific skin lesions observed except for excoriation and vague hyperpigmentation. A skin biopsy revealed only epidermal thinning with pigmentary incontinence. The patient was treated with 600 mg of gabapentin daily as well as capsaicin cream. The response was deemed unsatisfactory.

Notalgia paresthetica: a review for dermatologists

“…Differential diagnoses for localized pruritus with pigmentation on the back should be considered and include neurodermatitis, lichen simplex chronicus, tinea versicolor due to similar pigmentation and itch, pigmented contact dermatitis, and early cutaneous amyloidosis which typically affects the back …”

Dermoscopy of notalgia paresthetica

“…These fibrils are birefringent and under polarised dermoscopy appear as shiny white streaks [1]. Thus, shiny white streaks in notalgia paresthetica correspond histologically to amyloid fibrils [2]. Hyperpigmentation of various patterns seen dermoscopically corresponds to either basal pigmentation of the epidermis or melanophages with pigment incontinence in the dermis.…”

“…Medical Director, Rita Skin Foundation, Kolkata, India,2 Consultant Dermatologist, Rita Skin Foundation, Kolkata, India,…”

Gabapentin treatment in notalgia paresthetica: a preliminary report

“…Up to now, only one study and two case reports have documented therapeutic results for gabapentin in NP in a total of 12 patients . There were contradictory outcomes in two case reports; one reporting complete alleviation of itching with gabapentin at a dose of 600 mg/day, whereas the other reported unsatisfactory response to the drug at the same dose . However, in the largest series by Maciel et al ,.…”

“…In order to achieve a therapeutic effect, a step‐wise titration protocol is recommended, starting with a dose of 300 mg/day and gradually increasing the dose until the desired effect is attained, up to a maximum of 3,600 mg/day. Up to now, only one study and two case reports have documented therapeutic results for gabapentin in NP in a total of 12 patients . There were contradictory outcomes in two case reports; one reporting complete alleviation of itching with gabapentin at a dose of 600 mg/day, whereas the other reported unsatisfactory response to the drug at the same dose .…”