Medical Care
The best reported outcomes have been with antidepressant and anticonvulsant medications that affect nerve conduction. Gabapentin and pregabalin are commonly used. [36, 37, 38, 39]
Patients with brachioradial pruritus need time, sympathy, and understanding. They appreciate being told that they have a defined entity and that treatment options are available. Ice packs are helpful for immediate symptomatic relief, and other treatments can be tried in an outpatient setting. Frequent follow-up is often helpful emotionally for patients. Most cases remit in weeks to months.
Cervical nerve blocks have been reported to be unhelpful, [9] but cervical spine manipulation is effective in some patients. [1, 25] Cutaneous field stimulation has also been used. In one study, patients receiving 20 minutes of this treatment to affected areas once daily reported significant symptomatic improvement after 5 weeks. [40]
Acupuncture may be helpful for symptomatic relief. Stellon [41] performed a retrospective case series of 16 patients with brachioradial pruritus using deep intramuscular stimulation acupuncture to the paravertebral muscles in the dermatomal segments of the body affected by the pruritus. Treatment was also given to other segments of the body not affected by the pruritus if paravertebral spasm and tenderness was detected. After a median of 4 treatments, 12 of 16 patients reported complete resolution of symptoms and 4 patients reported partial resolution. Relapse occurred in 6 patients within 1-12 months of cessation of acupuncture.
One report describes dramatic improvement after injections with botulinum toxin A (100 IU/3 mL saline) in a 59-year-old white woman with longstanding brachioradial pruritus. [42] This patient received 4 series of injections and experienced significant improvement for 6 months following each series of injections. The authors point out that acetylcholine has been shown to be a mediator of itch in patients with atopic dermatitis, and they suggest that reduction in acetylcholine release mediated by botulinum toxin A may explain its helpfulness in the setting of brachioradial pruritus. They also postulate that botulinum toxin A may reduce histamine-mediated itch.
A compounded mixture of amitriptyline hydrochloride 1.0%, ketamine hydrochloride 0.5%, and Vanicream applied 2-3 times daily was reported to provide complete relief to an adult patient with a 5-year history of brachioradial pruritus unresponsive to conventional treatments. [43]
Compounded topical amitriptyline hydrochloride and ketamine hydrochloride can be helpful in brachioradial pruritus unresponsive to conventional treatments. [43, 44]
Aprepitant, a neurokinin-1 receptor inhibitor, can also be effective, even in long-standing disease refractory to conventional treatments. [45, 46]
Surgical Care
Surgical care is generally not indicated unless the patient has a documented cervical radiculopathy, cervical rib, or fibrous band impinging on the brachial plexus.
Consultations
Relief after physical therapy has been reported in case series, so consultation with a physical therapist or a chiropractor may be considered, particularly in patients with radiographic evidence of cervical spinal disease. Heyl [1] reported a case of one patient whose brachioradial pruritus developed after a neck injury, and symptoms were relieved by neck traction.
The authors have not found consultation with a neurologist or pain specialist to be of value.
Consultation with an acupuncturist may be helpful.
Some patients have psychiatric disorders that predispose to brachioradial pruritus, while others may develop anxiety, depression, obsessions/compulsions, or delusions of parasitosis in response to the exasperating symptoms.
Diet
No dietary modifications have been reported to alleviate symptoms.
Activity
Patients who notice exacerbation of symptoms with sunlight exposure benefit from restricting their time outdoors during peak sunlight hours (10 am to 2 pm). Often, wearing long-sleeved shirts when outdoors provides relief equal to that achieved with more sophisticated interventions. Sunscreens are typically less effective.
Prevention
Strict photoprotection with sunscreen and long-sleeved shirts can prevent recurrence of symptoms in some patients.
Long-Term Monitoring
Frequent outpatient follow-up of patients with brachioradial pruritus is often helpful.
-
Area of pruritus demarcated in pen in a middle-aged woman with brachioradial pruritus. Macroscopically, no skin changes are visible.
-
Subtle excoriations on the dorsal forearm of a middle-aged woman with brachioradial pruritus.
