What is the treatment for meralgia paresthetica?

Treatment of Meralgia Paresthetica

The treatment of meralgia paresthetica should follow a stepwise approach, beginning with conservative measures such as eliminating mechanical compression factors (tight clothing), using topical lidocaine, and oral neuropathic pain medications, before considering interventional procedures for refractory cases. 1, 2

Initial Management (0-3 months)

Conservative Measures

• Remove mechanical compression factors:
  • Avoid tight clothing, especially low-cut tight trousers 3
  • Weight reduction for patients with obesity 4, 3
  • Modify activities that exacerbate symptoms

Pharmacological Treatment

• Topical treatments:

  • Lidocaine patches (4% OTC or 5% prescription) applied to the affected area 1
  • Lidocaine cream/ointment as an alternative to patches 1

• Oral medications:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation 5
  • Neuropathic pain medications:
    • Gabapentin (starting at 300mg at bedtime, up to 2400mg daily in divided doses) 6
    • Pregabalin (75-300mg every 12 hours) 6
    • Amitriptyline (can be used topically or orally) 6

Physical Therapy

• Application of superficial heat or cold to the affected area (limit cold to 10 minutes) 1
• Manual mobilization techniques and massage of the affected area 1

Intermediate Phase (if symptoms persist after 3 months)

Interventional Procedures

• Local anesthetic with corticosteroid injection around the lateral femoral cutaneous nerve 1, 5, 3
  • This can also be diagnostic - relief of symptoms confirms the diagnosis 5
• Consider pulsed radiofrequency if injections provide only temporary relief 1

Advanced Phase (if symptoms persist after 6+ months)

Surgical Options

• Surgical decompression (neurolysis) of the lateral femoral cutaneous nerve 2, 4, 5
• Nerve transection (neurectomy) as a reserve option when neurolysis fails 2, 4
• Peripheral nerve stimulation for refractory cases in specialized centers 1, 7

Important Considerations

• The controversy between neurolysis versus neurectomy remains unresolved, but most evidence favors trying neurolysis first 4, 5
• Diagnostic confirmation can be achieved with local anesthetic injection (temporary relief of symptoms) and electrophysiologic studies (sensitive in approximately 83% of cases) 3
• Meralgia paresthetica can be confused with L4 or L5 radiculopathy, so consider this diagnosis especially in patients with obesity and diabetes who have chronic irritation of the anterolateral thigh and negative lumbar MRI findings 4
• Most cases respond well to conservative treatment, making surgical intervention necessary only in refractory cases 5

Treatment Algorithm

1. Start with conservative measures (remove compression, weight loss if applicable)
2. Add topical lidocaine and oral medications (NSAIDs, neuropathic pain medications)
3. If no improvement after 3 months, proceed to corticosteroid injections
4. For persistent symptoms beyond 6 months, consider surgical options (neurolysis first)
5. For intractable cases, consider peripheral nerve stimulation at specialized centers