Skin Pain on Upper Left Abdomen
Skin pain (cutaneous hypersensitivity) on the upper left abdomen without underlying visceral pathology is most commonly neuropathic in origin, but you must first exclude serious intra-abdominal causes that may present with referred or localized pain.
Immediate Diagnostic Priorities
Rule Out Serious Pathology First
Obtain CT with IV contrast for left-sided abdominal pain to exclude splenic, pancreatic, gastric, or renal pathology. 1, 2 This is the recommended first-line imaging when the diagnosis is unclear. 3
- Check complete blood count, liver function tests, pancreatic enzymes (amylase/lipase), and renal function tests to evaluate for underlying organ pathology 4
- Obtain pregnancy test in all women of reproductive age 4
- Consider lactate level if severe pain or signs of ischemia are present 4
Key Clinical Distinctions
True "skin pain" (allodynia or hyperesthesia confined to the skin surface) differs fundamentally from deeper visceral or somatic pain:
- Skin pain worsens with light touch or clothing contact and follows dermatomal patterns
- Visceral pain from organs (spleen, pancreas, stomach, kidney) is typically deeper, poorly localized, and associated with systemic symptoms 2, 5
- Left upper quadrant visceral causes include pancreatitis, splenic pathology, gastric disease, or renal stones 1, 3
Common Causes of True Cutaneous Pain
Neuropathic Etiologies
Herpes zoster (shingles) is the most common cause of dermatomal skin pain in the abdomen:
- May present with pain 2-7 days before rash appears
- Follows thoracic dermatomes (T7-T10 for upper abdomen)
- Requires early antiviral therapy if diagnosed within 72 hours of rash onset
Post-herpetic neuralgia or intercostal neuralgia:
- Persistent pain along nerve distribution
- May occur after trauma, surgery, or spontaneously
Other Cutaneous Causes
Cutaneous mastocytosis can present with skin pain, flushing, and pruritus, though this is rare in adults and typically presents with visible lesions. 6 Darier's sign (urtication with rubbing) may be present. 6
Contact dermatitis or localized skin inflammation may cause superficial burning or stinging pain.
Management Algorithm
If Imaging and Labs Are Normal
For neuropathic skin pain without identified visceral pathology:
First-line treatment: Tricyclic antidepressants (e.g., nortriptyline 10-25mg at bedtime, titrate up) for neuropathic pain 6
Alternative agents: Gabapentin or pregabalin if tricyclics are contraindicated
Topical therapy: Lidocaine patches or capsaicin cream for localized areas
Avoid opioids due to risk of narcotic bowel syndrome and lack of efficacy for neuropathic pain 1
If Visceral Pathology Is Identified
Treat according to specific diagnosis:
- Pancreatitis: Supportive care, bowel rest, analgesia 1
- Splenic pathology: Surgical consultation if rupture or significant hematoma 4
- Diverticulitis: Conservative management without antibiotics if uncomplicated and immunocompetent 1
- Gastric causes: Proton pump inhibitors, consider endoscopy 6
Critical Pitfalls to Avoid
Do not dismiss localized skin pain as "functional" without imaging - serious pathology like splenic infarction or pancreatic disease can present with referred cutaneous hypersensitivity 1, 2
Do not attribute symptoms to fatty liver disease - hepatic steatosis does not cause left upper quadrant pain and requires separate evaluation 3
Do not delay imaging in patients with severe pain, fever, or systemic symptoms - these suggest serious intra-abdominal pathology requiring urgent intervention 1, 7
Consider herpes zoster even before rash appears - early antiviral treatment is most effective within 72 hours
Follow-Up Recommendations
If no cause is identified after comprehensive workup, consider: