How is paresthesia managed and treated?

Management and Treatment of Paresthesia

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

Identifying the Cause

• Paresthesia can originate from various causes including central nervous processes, trauma, surgery, inflammations, tumors, systemic conditions, or degenerative processes 2
• Common causes include diabetic neuropathy, nerve entrapment syndromes (particularly carpal tunnel syndrome), vitamin B12 deficiency, and other systemic conditions 3
• Careful evaluation of symptom pattern is crucial - acute onset, rapidly progressive, severe, asymmetric, or proximal paresthesias may indicate serious conditions like Guillain-Barré syndrome requiring urgent management 3

Treatment Based on Specific Causes

Neuropathic Paresthesia

• For diabetic peripheral neuropathy, first-line medications include:

  • Anticonvulsants: pregabalin and gabapentin 1
  • Sodium channel blockers: lamotrigine and oxcarbazepine 1
  • Tricyclic antidepressants may be considered but can have significant side effects 1

• For painful paresthesias, medications such as phenytoin, carbamazepine, oxcarbazepine, gabapentin, and topiramate may be effective 4

• Patients on carbamazepine require monitoring for serious adverse effects including Stevens-Johnson syndrome 1

Orthostatic Hypotension-Related Paresthesia

• Non-pharmacologic measures are recommended:

  • Ensuring adequate salt intake
  • Avoiding medications that aggravate hypotension
  • Using compressive garments over legs and abdomen
  • Physical activity to avoid deconditioning 5

• Pharmacologic options include:

  • Shorter-acting drugs at bedtime (guanfacine, clonidine)
  • Shorter-acting calcium blockers (isradipine)
  • Shorter-acting β-blockers (atenolol, metoprolol tartrate) 5

Entrapment Neuropathies

• For carpal tunnel syndrome, nocturnal splints are recommended 4
• Ultrasound-guided steroid injections may be beneficial for nerve entrapment syndromes 3
• Surgical decompression may be necessary in severe or refractory cases 3

Gastroparesis-Related Paresthesia

• Dietary modifications:

  • Frequent smaller meals
  • Low-fat and low-fiber diet
  • More liquid calories and foods with small particle size 5, 6

• Pharmacologic therapy:

  • Metoclopramide (10mg three times daily before meals) - but limit use to 12 weeks due to risk of extrapyramidal symptoms 5, 6
  • Erythromycin is effective for short-term use but limited by tachyphylaxis 5, 6
  • Avoid medications that worsen symptoms (opioids, anticholinergics, tricyclic antidepressants) 5

• For refractory cases:

  • Botulinum toxin injection into the pylorus
  • Gastric electrical stimulation
  • Gastrostomy/jejunostomy tubes 5, 1

Psychogenic Paresthesia

• Antidepressants may be effective for paresthesia associated with anxiety or depression 7
• Fluoxetine at doses of 40mg/day has shown efficacy in case reports 7

Physical Therapy and Rehabilitation

• For Guillain-Barré syndrome and other neuropathies, rehabilitation programs should aim to:

  • Reduce disability in early stages
  • Restore motor and sensory function
  • Improve physical condition 5

• Exercise programs including range-of-motion exercises, stationary cycling, walking, and strength training can improve:

  • Physical fitness
  • Walking ability
  • Independence in activities of daily living 5

• Caution: Exercise intensity must be closely monitored as overwork can cause fatigue 5

Managing Specific Symptoms

Pain

• Chronic pain in neuropathies may present as muscle pain, painful paresthesias, arthralgia, or radicular pain 5
• Management strategies include:
  • Encouraging mobilization for muscle pain and arthralgia
  • Administering medications for neuropathic or nociceptive pain 5
  • In persistent cases, neurostimulation techniques may be considered 4

Fatigue

• Fatigue is common in conditions like Guillain-Barré syndrome (60-80% of patients) 5
• A graded, supervised exercise program has shown efficacy in reducing fatigue 5

Monitoring and Follow-up

• Regular assessment of symptom improvement is essential 1
• For diabetic neuropathy, comprehensive foot evaluation at least annually is recommended 5
• Monitor for medication side effects, particularly with anticonvulsants and tricyclic antidepressants 1

Important Considerations and Pitfalls

• Load-related paresthesias (such as from backpacks) require addressing the mechanical cause - proper load distribution, wider straps, and weight reduction 8
• Avoid diazepam or other benzodiazepines during stroke recovery due to possible deleterious effects on recovery 5
• For spasticity-related paresthesia, consider antispastic positioning, range of motion exercises, stretching, and splinting 5