A-Z OF SKIN

Notalgia paraesthetica

Notalgia paraesthetica

What is notalgia paraesthetica?

Notalgia paraesthetica is a disorder where an often intense localised itch occurs without a rash on the mid to upper back between the shoulder blades. It is thought to be due to sensory nerve irritation rather than a primary skin condition. It tends to run a chronic course. There is currently no cure but there are treatments that can help control the itch.

What causes it?

Notalgia paraesthetica is due to injury to the nerves that supply the skin of the affected area. These nerves originate in the spinal cord of the upper back and then run a long course through the thick back muscles before reaching the skin. The nerves may be injured anywhere along this path.

  • In the spine, nerve injury may be due to chronic degenerative changes or an acute back injury.
  • In the muscles, nerve injury may be due to muscle inflammation or disease.
  • In the skin, nerve injury may be due to sunburn or shingles.

What does it look like?

The first sign of notalgia paraesthetica is  itch. This is typically localised to an area of skin just between or below the shoulder blade on either side of the back. Some people will also experience burning pain, tenderness and increased sensitivity of the skin in that area. The changes seen on the skin are usually the result of repeated scratching and rubbing.  This may lead to the skin in the area becoming darker in colour.

How is it diagnosed?

The diagnosis is usually made by a dermatologist and is based on history of an episodic intense itch plus clinical examination.  If the history or physical examination indicates the possibility of a spinal or muscular problem further investigation may be needed.

How is it treated?

Currently there is no cure for notalgia paraesthetica.  However, many treatments are available to help reduce the itch. Reassurance that there is no major medical problem is important.

  • Topical treatments (creams) are used to directly reduce inflammation or “trick the nerves” into not sending the message of itch/pain to the brain. Examples of topical treatments include:
    • Cooling creams (containing menthol and/or phenol and/or camphor)
    • Cold packs applied to the irritable area when it is symptomatic can be helpful
    • Capsaicin cream
    • Local anaesthetic creams
    • Other compounded creams (containing doxepin, amitryptiline and ketamine)

Because of the intermittent nature of symptoms, notalgia paraesthetica is mostly managed with the use of topical preparations. If the symptoms are more persistent or troublesome additional treatments may be tried.

  • Oral treatments (tablets) reduce the sensation of nerve irritation.  Examples of oral treatments include:
    • Doxepin
    • Amitriptyline
    • Gabapentin or pregabalin
  • Injectable treatments
    • Botulinum toxin
    • Paravertebral local anaesthetic block
  • Peripheral nerve field stimulation
    • Transcutaneous electrical nerve stimulation
    • Subcutaneous electrical nerve stimulation
    • Acupuncture
  • Back support
    Enhancing your back support may also be helpful and your doctor may suggest:

    • An ergonomic assessment
    • Physiotherapy
    • Simple exercises and stretches. A recent study demonstrated an improvement in patient symptoms with simple exercises and stretches as outlined here (Australasian Journal of Dermatology 2016. 57, 222-224).

    What is the likely outcome of the condition?

    Notalgia paraesthetica typically runs a chronic course. In most people the itch is mild, but it can be quite debilitating in others.

    This information has been written by Dr Bernadette Ricciardo
    Last Updated 29/05/2017