Notalgia Paresthetica Treatment & Management

Notalgia paresthetica (NP) is often refractory to standard dermatological treatments. Previously, no clearly described etiology and no uniformly effective treatment had been reported for notalgia paresthetica. Topical antipruritic compounds containing camphor and menthol traditionally have been used and have been reported as being of some benefit, albeit limited, as may topical capsaicin. Therefore, treatment of notalgia paresthetica with topical modalities, including topical steroids, generally yields partial-to-negligible responses. While topical therapies may, in some cases, seemingly help decrease the localized symptoms of notalgia paresthetica, systemic or broader-scope spinal evaluation and therapy may be warranted to fully evaluate refractory cases.

It is important to note that during the initial assessment of patients with notalgia paresthetica, a thorough history should be obtained and any findings of osteoarthritis, prior neck trauma, motor vehicle accidents, vertebral fracture, cervical neoplasm or malignancy, or cervical disk disease should be noted. 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 first-line treatment for patients with notalgia paresthetica with underlying spinal disease is evaluation and conservative management of their spine and paraspinal muscles by physical therapy, massage, spinal manipulation, acupuncture, orthopedic surgery, pain management, and other musculoskeletal management. Agents such as oral gabapentin used for neuropathic pain have demonstrated some efficacy. ^[16]

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. While additional large scale studies are likely needed to further assess the relationship of notalgia paresthetica with cervical spine disease, the current literature supports that an association exists.

Currently, first-line therapy for notalgia paresthetica with associated cervical disease may include nondermatologic, noninvasive treatments such as spinal manipulation, ^[17] physical therapy, cervical soft collars, massage, cervical traction, ^[18] cervical muscle strengthening and increasing range of motion, transcutaneous electrical nerve stimulation (TENS), ^[19] 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. ^[20] 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. ^[21] Successful treatment with botulinum toxin A has also been reported. ^[22] 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), IgE level, chest radiography, thyrotropin, and in some cases serum protein electrophoresis, may be warranted to exclude underlying physiologic causes of pruritus.

Surgical therapy for notalgia paresthetica (NP) with associated cervical disease may include trigger-point injections and steroid injections, and cervical nerve and/or paravertebral blocks for severe or highly refractory cases. Other treatments include 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, 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.

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.

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.