From the Guidelines
The best management approach for notalgia paresthetica involves a multimodal strategy combining topical treatments, oral medications, and physical interventions. This approach is based on the understanding that neuropathic pruritus, such as notalgia paresthetica, is caused by pathology along the afferent pathway of the nervous system, including peripheral nervous system issues like nerve fibre compression or degeneration 1. First-line treatment typically includes topical capsaicin 0.025-0.075% cream applied 3-4 times daily to the affected area, which works by depleting substance P from sensory nerve endings to reduce itch and pain.
Key Management Strategies
- Topical anesthetics like lidocaine 5% patches or cream can provide temporary relief when applied to the affected area for 12 hours daily.
- Oral medications such as gabapentin (starting at 300mg daily and titrating up to 300mg three times daily as needed) or amitriptyline (10-25mg at bedtime) may help manage neuropathic symptoms.
- Physical interventions including physical therapy focusing on thoracic spine mobilization, stretching exercises, and postural correction can address underlying musculoskeletal contributors.
- Some patients benefit from botulinum toxin injections (50-100 units) into the affected area every 3-4 months, which blocks acetylcholine release at nerve terminals. Treatment should be individualized based on symptom severity, with most patients requiring combination therapy for optimal relief, as notalgia paresthetica is often related to degenerative changes in the spine, affecting the dorsal cutaneous nerves (typically T2-T6) 1.
From the Research
Management Approach for Notalgia Paresthetica
The best management approach for notalgia paresthetica involves a combination of treatment options, including topical agents, systemic agents, procedural modalities, and physical therapy.
- Topical agents such as capsaicin, tacrolimus, anesthetic cream, and amitriptyline/ketamine can be effective in relieving pruritus and pain 2, 3, 4.
- Systemic agents like gabapentin, oxcarbazepine, and amitriptyline can also be used to manage symptoms 2, 5.
- Procedural modalities such as botulinum toxin A and narrowband UVB may be considered for patients who do not respond to topical or systemic treatments 2.
- Physical therapy can be combined with other treatment options to achieve a sustained treatment response 2.
Treatment Algorithm
A treatment algorithm for notalgia paresthetica suggests starting with topical agents or physical therapy, followed by systemic agents, and finally procedural modalities 2.
- Topical capsaicin has been shown to be effective in relieving pruritus in approximately 70% of patients 3.
- Gabapentin has been found to be effective in improving pruritus and quality of life in patients with notalgia paresthetica 5.
- The use of 8% capsaicin topical patches has also been reported to be effective in relieving chronic pruritus in some patients with notalgia paresthetica, although the duration of effectiveness can vary greatly 4.
Symptom Burden and Treatment Patterns
A survey of dermatologists found that pruritus was the most common symptom reported by patients with notalgia paresthetica, followed by hyperpigmentation and sensitive skin 6.
- The most burdensome symptom was pruritus, followed by burning or hot sensation, and painful or raw skin 6.
- The most prescribed treatments included non-medicated skin care, topical corticosteroids, oral antihistamines, medicated topicals, and gabapentin or pregabalin 6.
- Physicians reported low satisfaction with available treatments, with the most common reason for discontinuing therapy being lack of response 6.