Medication Summary
While no uniformly effective topical treatment has been reported for the cutaneous symptoms of notalgia paresthetica (NP), common first-line dermatologic medications have previosuly typically included potent topical steroid creams and topical antipruritics like capsaicin.
Prior to the new paradigm shift in treatment of the underlying spine as first-line therapy, previously accepted therapeutic options for the localized itch syndromes included capsaicin cream, [23] eutectic mixture of local anesthetic (EMLA) cream, topical steroids, pramoxine cream, topical cooling or ice pack applications, oral steroids, Tiger balm, camphor and menthol creams, flurandrenolide tape (Cordran Tape), intralesional corticosteroid injections, botulinum toxin injections, [22] oral antihistamines, hydroxyzine, doxepin, topiramate (Topamax), anticonvulsant medications, carbamazepine (Tegretol), antidepressant medications, gabapentin (Neurontin), oxcarbazepine, [24] and thalidomide. [25]
Second-line therapy for notalgia paresthetica includes medications such as oral nonsteroidal anti-inflammatory medications (eg, ibuprofen, celecoxib, ketorolac) and oral muscle relaxants (eg, carisoprodol, cyclobenzaprine, methocarbamol, metaxalone).
It is relevant to note that some of the systemic or oral therapies may exert their effect through the spinal nerves and central nervous system, thereby supporting the neuropathic etiology of notalgia paresthetica. [8, 15]
More important is that there is now a new shift in the treatment of notalgia paresthetica with therapies aimed at the spine, not the skin. [4, 5, 15, 17, 18]
Topical corticosteroid (very high potency)
Clobetasol propionate (Temovate, Clobex, Cormax)
Clobetasol propionate is a class I superpotent topical steroid; it suppresses mitosis and increases the synthesis of proteins that decrease inflammation and cause vasoconstriction. Clobetasol propionate decreases inflammation by stabilizing lysosomal membranes, inhibiting PMN and mast cell degranulation.
Topical corticosteroid (high potency)
Fluocinonide (Lidex)
Fluocinonide is a high-potency steroid that inhibits cell proliferation. It is immunosuppressive, antiproliferative, and anti-inflammatory. Fluocinonide also has antipruritic and vasoconstrictive properties.
Topical corticosteroid (medium potency)
Triamcinolone topical (Aristacort)
Triamcinolone topical is used for inflammatory dermatosis responsive to steroids; it decreases inflammation by suppressing the migration of PMNs and reversing capillary permeability. It is available in ointment (0.1%) and cream (0.025%, 0.1%, 0.5%).
Antipruritic
Hydroxyzine hydrochloride (Atarax, Vistaril)
Hydroxyzine hydrochloride antagonizes H1 receptors in the periphery. It may suppress histamine activity in the subcortical region of CNS.
Topical analgesic
Capsaicin topical (Capzasin-P and Zostrix)
Capsaicin is a natural chemical derived from plants of the Solanaceae family. It penetrates deep for temporary relief of minor aches and pains of muscles and joints associated inflammatory reactions. Capsaicin may render skin and joints insensitive to pain by depleting substance P in peripheral sensory neurons. It has demonstrated effectiveness in several studies of diabetic neuropathic pain and in other types of neuropathic pain.
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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.
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Mildly hyperpigmented skin of right infrascapular back. Courtesy of Dr. Nili Alai, The Skin Center at Laguna.
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MRI of the cervical spine demonstrating disc bulges at C5-C6. Courtesy of Dr. Nili Alai, The Skin Center at Laguna.
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Refractory notalgia mid-back in female who later developed systemic lymphoma. Courtesy of Dr. Nili Alai, The Skin Center at Laguna.
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Atypical Notalgia Paresthetica Low Back: Zosteriform erosions in appearance but lesions cross midline. Courtesy of Dr. Nili Alai, The Skin Center at Laguna.
