Chronic itch on the upper back, with pain

A 47-year-old man had had a chronic itch on his back for 2 years. He had no history of trauma to the site, nor did he recall applying topical products to that area.

He was otherwise healthy. He worked as an electrician and said he occasionally experienced cervical and back pain while working.

An examination revealed two grayish-brown ovoid patches on the upper back, each 5 cm to 7 cm in diameter (Figure 1).

DIAGNOSIS: NOTALGIA PARESTHETICA

Chronic, brown-gray, itching patches on the back in an adult patient are characteristic of notalgia paresthetica.

Conditions that may be included in the differential diagnosis but that do not match the presentation in this patient include the following:

• Cutaneous sarcoidosis, which may exhibit several morphologies, but itching would be unusual
• Chronic discoid lupus erythematosus, characterized by scarring and atrophic plaques, but mainly on the face and scalp
• Contact dermatitis, an itchy eczematous condition, characterized by scaly erythematous plaques
• Lichen amyloidosis, a variant of cutaneous amyloidosis characterized by the deposition of amyloid or amyloid-like proteins in the dermis, resulting in red-brown hyperkeratotic lichenoid papules, usually on the pretibial surfaces.

CAUSES AND MANAGEMENT

Notalgia paresthetica is a neuropathic syndrome of the skin of the middle of the back characterized by localized pruritus.^1–3 Although common, it often goes undiagnosed.^1,3,4 It tends to be chronic, with periodic remissions and exacerbations.

Notalgia paresthetica is thought to be a sensory neuropathy and may result from compression of the posterior rami of spinal nerve segments T2 to T6. Slight degenerative changes are often but not always observed, and their clinical significance is uncertain.^1,2,4 The condition affects people of all races and both sexes, usually adults ages 40 to 80.

Clinically, it presents as localized pruritus on the back, usually within the dermatomes T2 to T6.⁵ Examination reveals a hyperpigmented patch, sometimes with excoriations.⁵

Diagnosis is based on clinical findings. Laboratory tests are not useful. Imaging is not needed, but magnetic resonance imaging and evaluation by an orthopedic surgeon are appropriate when there is chronic focal pain. Skin biopsy is usually not necessary, although it may be useful in some patients to exclude other conditions. When biopsy is done, macular amyloidosis or postinflammatory hyperpigmentation is seen.

Treatment is difficult. Topical steroids and oral antihistamines are usually ineffective,⁵ but topical capsaicin may provide temporary relief.³ The most recommended treatment in patients with notalgia paresthetica and underlying spinal disease is evaluation and conservative management of the spinal disease, including progressive exercise and rehabilitation.² Other therapies include oxcarbazepine, gabapentin, transcutaneous electrical nerve stimulation, phototherapy,⁶ and botulinum toxin injection.

TREATMENT OF OUR PATIENT

In our patient, an orthopedic evaluation revealed cervicothoracic scoliosis. He underwent 6 months of conservative treatment under the care of his family physician and a dermatologist. Treatment consisted of exercise and rehabilitation for his scoliosis, and daily application of topical mometasone. The pain and itch gradual improved.

A 47-year-old man had had a chronic itch on his back for 2 years. He had no history of trauma to the site, nor did he recall applying topical products to that area.

He was otherwise healthy. He worked as an electrician and said he occasionally experienced cervical and back pain while working.

An examination revealed two grayish-brown ovoid patches on the upper back, each 5 cm to 7 cm in diameter (Figure 1).

DIAGNOSIS: NOTALGIA PARESTHETICA

Chronic, brown-gray, itching patches on the back in an adult patient are characteristic of notalgia paresthetica.

Conditions that may be included in the differential diagnosis but that do not match the presentation in this patient include the following:

• Cutaneous sarcoidosis, which may exhibit several morphologies, but itching would be unusual
• Chronic discoid lupus erythematosus, characterized by scarring and atrophic plaques, but mainly on the face and scalp
• Contact dermatitis, an itchy eczematous condition, characterized by scaly erythematous plaques
• Lichen amyloidosis, a variant of cutaneous amyloidosis characterized by the deposition of amyloid or amyloid-like proteins in the dermis, resulting in red-brown hyperkeratotic lichenoid papules, usually on the pretibial surfaces.

CAUSES AND MANAGEMENT

Notalgia paresthetica is a neuropathic syndrome of the skin of the middle of the back characterized by localized pruritus.^1–3 Although common, it often goes undiagnosed.^1,3,4 It tends to be chronic, with periodic remissions and exacerbations.

Notalgia paresthetica is thought to be a sensory neuropathy and may result from compression of the posterior rami of spinal nerve segments T2 to T6. Slight degenerative changes are often but not always observed, and their clinical significance is uncertain.^1,2,4 The condition affects people of all races and both sexes, usually adults ages 40 to 80.

Clinically, it presents as localized pruritus on the back, usually within the dermatomes T2 to T6.⁵ Examination reveals a hyperpigmented patch, sometimes with excoriations.⁵

Diagnosis is based on clinical findings. Laboratory tests are not useful. Imaging is not needed, but magnetic resonance imaging and evaluation by an orthopedic surgeon are appropriate when there is chronic focal pain. Skin biopsy is usually not necessary, although it may be useful in some patients to exclude other conditions. When biopsy is done, macular amyloidosis or postinflammatory hyperpigmentation is seen.

Treatment is difficult. Topical steroids and oral antihistamines are usually ineffective,⁵ but topical capsaicin may provide temporary relief.³ The most recommended treatment in patients with notalgia paresthetica and underlying spinal disease is evaluation and conservative management of the spinal disease, including progressive exercise and rehabilitation.² Other therapies include oxcarbazepine, gabapentin, transcutaneous electrical nerve stimulation, phototherapy,⁶ and botulinum toxin injection.

TREATMENT OF OUR PATIENT

In our patient, an orthopedic evaluation revealed cervicothoracic scoliosis. He underwent 6 months of conservative treatment under the care of his family physician and a dermatologist. Treatment consisted of exercise and rehabilitation for his scoliosis, and daily application of topical mometasone. The pain and itch gradual improved.

A 47-year-old man had had a chronic itch on his back for 2 years. He had no history of trauma to the site, nor did he recall applying topical products to that area.

He was otherwise healthy. He worked as an electrician and said he occasionally experienced cervical and back pain while working.

An examination revealed two grayish-brown ovoid patches on the upper back, each 5 cm to 7 cm in diameter (Figure 1).

DIAGNOSIS: NOTALGIA PARESTHETICA

Chronic, brown-gray, itching patches on the back in an adult patient are characteristic of notalgia paresthetica.

Conditions that may be included in the differential diagnosis but that do not match the presentation in this patient include the following:

• Cutaneous sarcoidosis, which may exhibit several morphologies, but itching would be unusual
• Chronic discoid lupus erythematosus, characterized by scarring and atrophic plaques, but mainly on the face and scalp
• Contact dermatitis, an itchy eczematous condition, characterized by scaly erythematous plaques
• Lichen amyloidosis, a variant of cutaneous amyloidosis characterized by the deposition of amyloid or amyloid-like proteins in the dermis, resulting in red-brown hyperkeratotic lichenoid papules, usually on the pretibial surfaces.

CAUSES AND MANAGEMENT

Notalgia paresthetica is a neuropathic syndrome of the skin of the middle of the back characterized by localized pruritus.^1–3 Although common, it often goes undiagnosed.^1,3,4 It tends to be chronic, with periodic remissions and exacerbations.

Notalgia paresthetica is thought to be a sensory neuropathy and may result from compression of the posterior rami of spinal nerve segments T2 to T6. Slight degenerative changes are often but not always observed, and their clinical significance is uncertain.^1,2,4 The condition affects people of all races and both sexes, usually adults ages 40 to 80.

Clinically, it presents as localized pruritus on the back, usually within the dermatomes T2 to T6.⁵ Examination reveals a hyperpigmented patch, sometimes with excoriations.⁵

Diagnosis is based on clinical findings. Laboratory tests are not useful. Imaging is not needed, but magnetic resonance imaging and evaluation by an orthopedic surgeon are appropriate when there is chronic focal pain. Skin biopsy is usually not necessary, although it may be useful in some patients to exclude other conditions. When biopsy is done, macular amyloidosis or postinflammatory hyperpigmentation is seen.

Treatment is difficult. Topical steroids and oral antihistamines are usually ineffective,⁵ but topical capsaicin may provide temporary relief.³ The most recommended treatment in patients with notalgia paresthetica and underlying spinal disease is evaluation and conservative management of the spinal disease, including progressive exercise and rehabilitation.² Other therapies include oxcarbazepine, gabapentin, transcutaneous electrical nerve stimulation, phototherapy,⁶ and botulinum toxin injection.

TREATMENT OF OUR PATIENT

In our patient, an orthopedic evaluation revealed cervicothoracic scoliosis. He underwent 6 months of conservative treatment under the care of his family physician and a dermatologist. Treatment consisted of exercise and rehabilitation for his scoliosis, and daily application of topical mometasone. The pain and itch gradual improved.