What is the treatment for paresthesia?

Treatment of Paresthesia

The treatment of paresthesia must be directed at the underlying cause, with specific medications like anticonvulsants (carbamazepine/oxcarbazepine) being first-line for neuropathic causes, while non-pharmacologic measures are essential for conditions like orthostatic hypotension. 1

Identifying the Cause of Paresthesia

Paresthesia (numbness, tingling, prickling sensations) can result from various underlying conditions that require different treatment approaches:

• Paresthesia may be caused by abnormalities anywhere along the sensory pathway from peripheral nerves to the cerebral cortex 2
• Common causes include:
  • Diabetic neuropathy 1
  • Nerve entrapment syndromes (e.g., carpal tunnel syndrome) 2, 3
  • Vitamin B12 deficiency 2
  • Monoclonal gammopathy 2
  • Fabry's disease 2
  • Psychogenic causes (anxiety, depression) 4
  • Load-related compression (e.g., rucksack palsy) 5

Treatment Based on Specific Causes

Diabetic Peripheral Neuropathy

• First-line medications:
  • Anticonvulsants: pregabalin, gabapentin 1
  • Sodium channel blockers: lamotrigine, lacosamide, oxcarbazepine, valproic acid 1
  • Tricyclic antidepressants (e.g., amitriptyline) - may be limited in patients ≥65 years due to anticholinergic side effects 1
• For refractory cases, combination therapy may be necessary 1

Orthostatic Hypotension-Related Paresthesia

• Non-pharmacologic measures:
  • Ensuring adequate salt intake 1
  • Avoiding medications that aggravate hypotension 1
  • Using compressive garments over legs and abdomen 1
  • Physical activity and exercise to prevent deconditioning 1
  • Volume repletion with fluids and salt 1
• Pharmacologic measures:
  • FDA-approved medications: midodrine and droxidopa 1
  • For nighttime hypertension: shorter-acting agents like guanfacine, clonidine, isradipine, or shorter-acting beta-blockers 1

Paroxysmal Kinesigenic Dyskinesia (PKD)

• Anticonvulsants, particularly sodium channel blockers:
  • First-line: carbamazepine (initial dose 50 mg/day) or oxcarbazepine (initial dose 75 mg/day) 1
  • For pediatric patients: carbamazepine starting at 1 mg/kg 1
  • For patients with HLA-B*15:02 or who cannot tolerate carbamazepine: lamotrigine, topiramate, or phenytoin sodium 1
• Dosage should be individualized based on symptom control and side effects 1
• HLA-B*15:02 screening recommended before starting carbamazepine in Han Chinese populations 1

Gastroparesis-Related Paresthesia

• Dietary modifications:
  • Frequent smaller meals 1
  • Low-fat, low-fiber diet 1
  • More liquid calories (soups) 1
  • Foods with smaller particle size 1
• Pharmacologic treatment:
  • Antiemetics for nausea/vomiting (prochlorperazine, trimethobenzamide, promethazine) 1
  • Prokinetic agents: metoclopramide (FDA-approved but use limited to 12 weeks due to risk of extrapyramidal effects) 1
  • Erythromycin (effective short-term but develops tachyphylaxis) 1
• For refractory cases:
  • Botulinum toxin injection into the pylorus 1
  • Gastric electrical stimulation 1
  • Gastrostomy/jejunostomy tubes for decompression and feeding 1

Nerve Entrapment Syndromes

• For carpal tunnel syndrome and other entrapment neuropathies:
  • Ultrasound-guided steroid injections 2
  • Surgical release of entrapped nerves 2, 3
• For load-related paresthesias (e.g., rucksack palsy):
  • Reduce load weight and improve distribution 5
  • Use wider, better-padded straps and hip belts 5
  • Neck joint and nerve mobilization techniques 5

Psychogenic Paresthesia

• Antidepressant therapy (e.g., fluoxetine) for paresthesia associated with depression or anxiety 4
• Psychotherapy may be beneficial as adjunctive treatment 1

Monitoring and Follow-up

• Regular assessment of symptom improvement 1
• For diabetic neuropathy: comprehensive foot evaluation at least annually 1
• For patients with sensory loss: inspect feet at every visit 1
• Monitor for medication side effects, particularly with anticonvulsants and tricyclic antidepressants 1

Important Considerations and Pitfalls

• Acute onset, rapidly progressive, severe, asymmetric, or proximal paresthesia may indicate serious conditions like Guillain-Barré syndrome or vasculitis requiring urgent management 2
• Paresthesia associated with motor weakness requires prompt neurological evaluation 2
• For patients on carbamazepine, monitor for serious adverse effects including Steven-Johnson syndrome 1
• Avoid medications that can worsen symptoms (e.g., for gastroparesis: opioids, anticholinergics, tricyclic antidepressants) 1
• Recognize when specialty referral is needed (neurology, physical therapy, podiatry) 2, 5