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Notalgia Paresthetica

Notalgia Paresthetica is a chronic sensory neuropathy, with a characteristic location on the middle part of the back and primarily in the infrascapular area (unilateral involvement). This condition is also known as the hereditary localized pruritus, posterior pigmented pruritic patch or subscapular pruritus. It is a very common condition, affecting mainly those who are older.

Pathophysiology

It is believed that notalgia paresthetica occurs due to the increased sensory innervation existing in a certain skin area. The second possible mechanism has been connected to the degenerative disc disease that might affect the cervical or thoracic area, including a pinched nerve among other modifications.

Imaging investigations, such as X-rays have demonstrated that people who present their sensory neuropathy, also present degenerative changes in their vertebrae. The vertebrae that were affected by these problems corresponded to the dermatomes of the lesions present on the skin. Moreover, the histopathological analysis revealed the post-inflammatory hyperpigmentation at the level of the skin.

The symptoms that appear in patients diagnosed with notalgia paresthetica might also be related to the increased sensory innervation in the respective area. This has been encountered in patients diagnosed with lichen amyloid, this condition being caused in its turn by excessive scratching of the skin.

Notalgia paresthetica is believed to be a similar condition to the brachioradial pruritus, which is a localized pruritus syndrome as well. The latter has been found in association with degenerative disc disease (cervical) as well, which strengthened the idea that this might be a neuropathy as well and found in association with notalgia paresthetica. However, there is a main difference to be considered between these two medical conditions – notalgia paresthetica has a characteristic unilateral involvement whereas brachioradial pruritus can either have unilateral or bilateral involvement.

Symptoms of Notalgia Paresthetica

These are the most common symptoms present in patients diagnosed with notalgia paresthetica:

  • Itch in the interscapular area (corresponds to the thoracic dermatomes, between T2 and T6)
  • In some patients, the itch can extend to the other parts of the body, especially on the shoulders and the rest of the back, or even on the upper part of the chest; in very rare cases, the neck and the scalp might be involved
  • The itchiness can be quite intense, causing the patient to scratch and rub the skin
  • Most common – left part of the body, just below the shoulder blade
  • Other symptoms that may accompany the itch include:
    • Pain
    • Paresthesia – the patient describe the sensation as ‘pins and needles’
    • Hyperesthesia – increased sensitivity to different stimuli (temperature – hot or cold, touch or pain)
  • Due to the constant scratching or rubbing, the skin presents hyperpigmentation in the respective area
  • The patient might describe a spider-bite sensation or a prickly feeling
  • Female patients mistake the symptoms, considering they are caused by allergy to clothing tags or bras
  • The itchiness can be accompanied, in some cases, by a mild burning sensation or numbness
  • Patients might also describe a general discomfort in the respective area
  • Affected skin area ranges between 3 and 10 cm
  • Excoriations may occur on the skin due to the incessant scratching and rubbing
  • Other modifications that may occur on the skin include:
    • Lichenification
    • Lichen amyloid
    • Eczema
    • Xerosis
  • Tenderness can be present to the touch
  • The range of motion in the neck can be affected and cervical muscle spasms are present (degenerative disc disease symptoms)
  • The constant scratching and rubbing of the skin can predispose the patient to secondary bacterial infections.

What are the Causes of Notalgia Paresthetica?

The exact etiology of notalgia paresthetica has yet to be identified. However, the appearance of this condition is considered to be a dermatological sign, suggestive of an underlying systemic disease.

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It is important to understand that notalgia paresthetica is not a skin disease on its own but rather a part of a sensory neuropathic syndrome, often found in association with degenerative diseases of the spine. It is believed that the main cause behind the appearance of these symptoms is the actual nerve impingement that occurs due to the collapse of the vertebral body, but further research is required in order to confirm this theory.

Treatment

These are the treatment solutions used for patients diagnosed with notalgia paresthetica:

  • Topical steroids – not all patients respond well to this treatment (partial response)
  • Topical anti-itching creams – reduce the itchiness and soothe the skin, as they contain menthol and camphor
  • Topical capsaicin might be provided as a treatment to those who are suffering from intense itchiness
  • Gabapentin – this is a treatment recommended for those who are also experiencing neuropathic pain
  • NSAIDs – for the symptoms associated with the itchiness; recommended choices include: ibuprofen, celecoxib and ketorolac
  • Oral muscle relaxants – these are recommended to be administered in case of muscular spasms
  • Treatment of the underlying systemic disease (degenerative disease of the spine)
    • Orthopedic and neurological
    • Physical therapy
    • Cervical muscle strengthening
    • Spinal manipulation
    • Massage
    • Exercises to the increase the ROM (range of motion)
    • TENS (transcutaneous electrical nerve stimulation)
    • Cervical discectomy with fusion

Exercises

As notalgia paresthetica is often found in association with degenerative diseases of the spine (cervical, thoracic or cervico-thoracic), the exercises are recommended to improve the symptoms of the underlying systemic disease. After a thorough assessment of the spine, the physical therapist will jot down all the problems that have to be corrected: range of motion, muscle strengthening and functionality. All of these are going to become objectives of the treatment program, helping the physical therapist provide you with the best exercises for your problem.

Here are several exercises you can consider for your problems:

  • Lying on the mat, with the hands resting near the body, raise your head and try to bring your chin as close to the chest as you can. Do not force to go yourself over the limit of pain. Allow the range of motion to increase progressively. Repeat between 5-10 times.
  • Lying on the mat, with the hands spread from the body, maintained in horizontal abduction. Raise your hands in the air, bringing them into midline, with the palms facing each other. Lower your hands and repeat 5-10 times.
  • Lying with the face down on the mat, with the hands near your body, try raising your head as much as you can. Once again, avoid going farther than you can. Lower your head and repeat 5-10 times.

These exercises are meant to increase your range of motion in a gradual manner and strengthen your paravertebral muscles. As you progress with your physical therapy program, the therapist will also show you exercises that are meant to increase your overall functionality. Once the underlying condition improves, so will the sensory neuropathy.

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