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Notalgia Paresthetica Treatment & Management

  • Author: Ally N Alai, MD, FAAD; Chief Editor: Dirk M Elston, MD  more...
Updated: Apr 29, 2016

Medical Care

Notalgia paresthetica (NP) is often refractory to standard dermatological treatments. Treatment of notalgia paresthetica with topical modalities, including topical steroids, generally yields partial responses. To date, no clearly described etiology and no uniformly effective treatment has been reported for notalgia paresthetica. While topical therapies may, in some cases, seemingly help decrease the localized symptoms of notalgia paresthetica, systemic or broader-scope spinal evaluation may be warranted to fully evaluate refractory cases.

The first-line treatment for patients with notalgia paresthetica with underling spinal disease is evaluation and conservative management of their spinal disease by orthopedic surgeons or physical therapists. Topical antipruritic compounds containing camphor and menthol may be of some benefit, as may topical capsaicin. Agents such as gabapentin used for neuropathic pain have demonstrated some efficacy.[12]

Important to note is that during the initial assessment of patients with notalgia paresthetica, obtain a thorough history and note any findings of osteoarthritis, prior neck trauma, motor vehicle accident, vertebral fracture, cervical neoplasm or malignancy, or cervical disk disease. Even in the absence of a positive medical history, radiography or MRI of the cervical spine may aid in early diagnosis and treatment of degenerative spine disease.

The striking association of notalgia paresthetica with degenerative or traumatic cervicothoracic spine disease suggests that early spinal nerve impingement may contribute to the pathogenesis of the skin symptoms of the disease. Additional studies are needed to further assess the relationship of notalgia paresthetica with cervical spine disease.

In the future, first-line therapy for notalgia paresthetica with associated cervical disease may include nondermatologic, noninvasive treatments such as spinal manipulation,[13] physical therapy, cervical soft collars, massage, cervical traction, cervical muscle strengthening and increasing range of motion, transcutaneous electrical nerve stimulation (TENS),[14] cervical diskectomy with fusion, oral nonsteroidal anti-inflammatory medications (eg, ibuprofen, celecoxib, ketorolac), and oral muscle relaxants (eg, carisoprodol, cyclobenzaprine, methocarbamol, metaxalone).

Control studies on the treatment of notalgia paresthetica and related conditions are lacking.[15] A British general practitioner has reported a benefit for deep intramuscular stimulation acupuncture to the paravertebral muscles in the dermatomal segments of the body affected by pruritus in a small retrospective series with no controls.[16] Successful treatment with botulinum toxin A has also been reported.[17] Other medical and surgical measures for degenerative disk cervical disease and nerve impingement may also be considered.

For more generalized and chronic pruritus, laboratory evaluation, including complete blood cell count, chemistry panel (including renal and liver function tests), chest radiography, thyrotropin, and serum protein electrophoresis, may be warranted to exclude underlying physiologic causes of pruritus.


Surgical Care

Surgical therapy for notalgia paresthetica (NP) with associated cervical disease may include cervical nerve blocks and steroid injection, diskectomy with fusion, disk replacement surgery, minimally invasive injectable disk repair techniques, and other surgical measures for degenerative cervical disease and nerve impingement.



Proper evaluation and management of notalgia paresthetica (NP) may involve a multispecialty cooperative effort including dermatologists, radiologists, orthopedic surgeons, neurologists, pain management specialists, and, possibly, acupuncturists, massage therapists, and physical therapists.

Consultations with other specialists may be warranted based on radiologic findings and individual patient history and physical examination results.



No dietary treatments or associated factors are described in notalgia paresthetica (NP).



Certain physical activities may potentially worsen notalgia paresthetica (NP) via exacerbation of the underlying cervicothoracic spine disease.

In particular, physical activities that exacerbate neck spasm and activities that promote excessive forward bending of the head tend to worsen symptoms. Heavy lifting and forward movement of the arms in front of the body also tend to exacerbate symptoms in some patients. Prolonged personal computer work reportedly has caused an increase in neck posture problems and exacerbation of notalgia paresthetica in susceptible individuals.



Possible complications of notalgia paresthetica (NP) include skin excoriations, secondary skin infection, prurigo nodules, postinflammatory hyperpigmentation, lichen amyloid, and lichen simplex chronicus.



Treatment of any underlying musculoskeletal cervical pathology may help prevent, reverse, or delay the onset of notalgia paresthetica (NP) in some patients. Proper posture and cervical health may be important in the prevention of notalgia paresthetica in susceptible individuals. Moreover, treatment of underlying conditions predisposing an individual to pruritus and laboratory evaluation of such conditions may be helpful.


Long-Term Monitoring

Notalgia paresthetica (NP) may be most effectively treated by evaluation and therapy aimed at the cervical musculoskeletal system. Outpatient cervical spine and muscle treatment, including transcutaneous electrical nerve stimulation (TENS)/electrical muscle stimulation (EMS), acupuncture, physical therapy, and cervical traction modalities, may be considered. Physical therapy, chiropractic maneuvers, and massage treatment may all be effective interventions in addressing the underlying cervical disease.

For appropriate candidates with demonstrated cervical disease through orthopedic and/or physical therapy evaluation, home TENS/EMS units as well as cervical traction units are available, including the horizontally based Saunders traction device and many over-the-door hanging types of traction.

Contributor Information and Disclosures

Ally N Alai, MD, FAAD Medical Director, The Skin Center at Laguna; Former Professor, Department of Dermatology, Clinical Faculty and Preceptor, Department of Family Practice, University of California, Irvine, School of Medicine; Former Professor and Preceptor, Department of Family Practice Residency Training, Downey Medical Center; Expert Medical Reviewer, Medical Board of California; Expert Consultant, California Department of Consumer Affairs; Expert Reviewer, California Department of Registered Nursing

Ally N Alai, MD, FAAD is a member of the following medical societies: American Academy of Dermatology, American Society for MOHS Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Daniel J Hogan, MD Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; Investigator, Hill Top Research, Florida Research Center

Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, Canadian Dermatology Association

Disclosure: Nothing to disclose.


Dena Thompson, MS Boston University School of Medicine

Disclosure: Nothing to disclose.


We would like to acknowledge our appreciation for clinical photographs and study provided by The Skin Center at Laguna in Laguna Hills, California.

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Cervical spine MRI demonstrating cervical disk disease and multilevel degenerative changes from C4-C5 through C7-T1. Note multiple osteophyte complexes and small disk bulges. Courtesy of Dr. Nili Alai, The Skin Center at Laguna.
Mildly hyperpigmented skin of right infrascapular back. Courtesy of Dr. Nili Alai, The Skin Center at Laguna.
MRI of the cervical spine demonstrating disc bulges at C5-C6. Courtesy of Dr. Nili Alai, The Skin Center at Laguna.
Refractory notalgia mid-back in female who later developed systemic lymphoma. Courtesy of Dr. Nili Alai, The Skin Center at Laguna.
Atypical Notalgia Paresthetica Low Back: Zosteriform erosions in appearance but lesions cross midline. Courtesy of Dr. Nili Alai, The Skin Center at Laguna.
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