What is Notalgia Paresthetica?
Also known as “Hereditary Localized Pruritus,” “Subscapular Pruritus” “Posterior Pigmented Pruritic Patch,” Hereditary Localized Pruritus,” Notalgia Paresthetica is a chronic sensory neuropathy. It primarily affects the middle part of the back and the infrascapular region. It has a unilateral involvement. Notalgia Paresthetica is a common condition mainly affecting the older individuals. This condition manifests as a common localized itch. It has a unilateral involvement. Sometimes Notalgia Paresthetica can have a more widespread distribution, involving the back, shoulders and upper chest.
The main symptom of Notalgia Paresthetica is itching or pruritus on the back, typically on the left hand side, just beneath the shoulder blade. Other accompanying symptoms may be present such as pain, paresthesias (sensation of pins and needles), or hyperesthesia (increased sensitivity of the skin to sensory stimuli). In Notalgia Paresthetica there is a well circumscribed hyperpigmented area or a patch of in the affected region
The exact cause or origin of this condition is not clear. There is no cure for Notalgia Paresthetica and treatment is done to manage the symptoms.
Pathophysiology of Notalgia Paresthetica
According to experts, notalgia paresthetica develops because of increased sensory innervation present in a certain skin region. The other mechanism could be related to the degenerative disc disease, which can affect the cervical or thoracic area, including a pinched nerve. X-rays and other imaging investigations have shown that people, who present with sensory neuropathy, also have vertebral degenerative changes. The affected vertebrae corresponded to the dermatomes of the lesions, which were present on the skin. Other than this, histopathological analysis has also revealed post-inflammatory hyperpigmentation at the skin level. The symptoms which are seen in patients with notalgia paresthetica can also be associated to the increased sensory innervation in that respective region. Notalgia paresthetica is thought to resemble brachioradial pruritus, which is also a localized pruritus syndrome. Brachioradial pruritus has also been found related to degenerative disc disease, which underlines the possibility that this may be a neuropathy as well and is found in association with notalgia paresthetica. Nevertheless, there is a vital difference between these two medical conditions, where notalgia paresthetica has a distinctive unilateral involvement and brachioradial pruritus can have either unilateral or bilateral involvement.
Causes of Notalgia Paresthetica
The exact cause of notalgia paresthetica has not been identified yet. The appearance of Notalgia Paresthetica is believed to be a dermatological sign, which indicates an underlying systemic medical condition. Notalgia paresthetica is not a skin disease, but is a part of a sensory neuropathic syndrome, which is usually found in relation with degenerative diseases of the spine. The primary cause for the symptoms of Notalgia Paresthetica is thought to be nerve impingement, which occurs as a result of collapsing of a vertebral body. Research is still being carried out to confirm this theory.
Signs & Symptoms of Notalgia Paresthetica
- Notalgia Paresthetica patient would have symptoms of itching in the interscapular region which corresponds to the thoracic dermatomes, between T2 and T6.
- Sometimes, the symptoms of itching in Notalgia Paresthetica can spread to the other parts of the body, particularly to the shoulders and the entire back, or upper part of the chest. Rarely, it can spread to the neck and the scalp.
- The itching can be very severe resulting in the patient scratching and rubbing the skin furiously.
- Most commonly affected region in Notalgia Paresthetica is the left part of the body, just beneath the shoulder blade.
- There can be tenderness to touch.
- There is hyperpigmentation in the area where there is itching from the constant scratching or rubbing of the skin.
- Many times, female patients of Notalgia Paresthetica mistakenly think that these symptoms are occurring as a result of allergy to bras or clothing tags.
- Patient can feel a prickly feeling or a spider-bite sensation.
- Notalgia Paresthetica patient may also experience signs and symptoms of numbness or a mild burning sensation along with itchiness.
- There can be a general discomfort in the affected area.
- The affected skin region can be between 3 and 10 cm in size.
- There may be development of excoriations on the skin from constant rubbing and scratching of the skin.
- Other changes in the skin include: Lichenification, lichen amyloid, xerosis and eczema.
- The incessant rubbing and scratching of the skin increases the risk of secondary bacterial infection to the patient.
- Patient’s range of motion in the neck may be affected and Notalgia Paresthetica patient may also have spasms of the cervical muscle, which is one of the symptoms of degenerative disc disease.
Accompanying symptoms of Notalgia Paresthetica along with the itching include:
- Paresthesias which is a sensation of ‘pins and needles.’
- Hyperesthesia where the patient has increased sensitivity to different stimuli, such as hot/cold temperature, pain or touch.
Treatment for Notalgia Paresthetica
There is no cure for notalgia paresthetica. Treatment comprises of controlling the symptoms with the use of:
- Topical anti-itching creams help in reducing the itchiness and also in soothing the skin.
- Topical steroids can also give a good response, though not in everyone.
- For treating intense itching associated with Notalgia Paresthetica, topical capsaicin can be applied to help alleviate it.
- Gabapentin can be useful in those patients who are also having neuropathic pain.
- NSAIDs, such as ibuprofen and celecoxib, can be prescribed for the associated symptoms along with itching, such as pain and tenderness.
- Oral muscle relaxants are beneficial in relaxing the muscular spasms.
- Paravertebral nerve block and botulinum toxin injections are also beneficial for Notalgia Paresthetica. In recent research, intradermal injections comprising of botulinum toxin type A (Botox) have been successful in giving some relief.
- Treatment for underlying systemic disorder including spinal degenerative disease includes physical therapy, strengthening of the cervical muscle, massage, spinal manipulation, exercises to help increase range of motion, TENS (transcutaneous electrical nerve stimulation) and cervical discectomy with fusion.
Exercises for Notalgia Paresthetica
As mentioned previously, notalgia paresthetica is commonly found in association with degenerative diseases of the spine, therefore exercises are done to alleviate the symptoms of the underlying systemic condition. Exercises are done to improve the range of motion, strengthen the muscles and their functionality. The below exercises also help in strengthening the paravertebral muscles. As there is improvement in the underlying medical condition, the sensory neuropathy also improves.
Exercise for Notalgia Paresthetica #1
- Lie on the mat and keep your hands resting near your body.
- Raise your head and bring your chin as close to the chest as possible.
- Stop if you feel pain and do not force yourself.
- Gradually your range of motion will increase.
- Repeat 5-10 times.
Exercise for Notalgia Paresthetica #-2
- Lie down on the mat with your face down and your hands near your body.
- Try to raise your head as much as possible.
- Again, do not push yourself against any pain.
- Lower your head.
- Repeat 5-10 times.
Exercise for Notalgia Paresthetica #3
- Lie on the mat and keep your hands away from the body in a position of horizontal abduction.
- Lift up your hands in the air and bring them into midline with the palms facing each other.
- Slowly lower your hands.
- Repeat 5-10 times.