What is the treatment for paresthesia?

Treatment of Paresthesia

Treatment of paresthesia must be directed at the underlying cause, with anticonvulsants like pregabalin and gabapentin as first-line therapy for neuropathic causes, while drug-induced paresthesia (such as from tuberculosis treatment) requires pyridoxine supplementation. 1

Identify and Address the Underlying Cause

The most critical first step is determining the etiology, as paresthesia can arise from diverse pathologies including peripheral neuropathy, nerve entrapment, medication toxicity, or systemic disease. 2

Drug-Induced Paresthesia

• Pyridoxine (vitamin B6) supplementation is essential when paresthesia develops during tuberculosis treatment with isoniazid, as 21% of HIV-infected patients develop paresthesia during antituberculosis therapy. 3
• Immediately discontinue offending medications including opioids, anticholinergics, tricyclic antidepressants, and GLP-1 receptor agonists if these are contributing to symptoms. 1, 4

Diabetic Peripheral Neuropathy

• First-line pharmacologic treatment consists of anticonvulsants (pregabalin, gabapentin) or sodium channel blockers (lamotrigine, oxcarbazepine). 1
• Aggressively optimize glycemic control, as hyperglycemia directly worsens nerve function and perpetuates symptoms. 4
• Perform comprehensive foot evaluation at least annually to monitor progression. 1

Nerve Entrapment (Carpal Tunnel Syndrome)

• Carpal tunnel syndrome is the most common cause of acroparesthesia (paresthesia affecting fingers and toes). 2
• Ultrasonography can diagnose nerve entrapment by demonstrating nerve enlargement, hypoechogenic appearance, and increased intraneural vascularity. 2
• Ultrasound-guided steroid injection or surgical carpal tunnel release are effective treatment options. 2

Non-Pharmacologic Management

For Orthostatic Hypotension-Related Paresthesia

• Ensure adequate salt intake to maintain blood volume. 1
• Avoid medications that aggravate hypotension. 1
• Use compressive garments over legs and abdomen to prevent venous pooling. 1
• Maintain physical activity to avoid deconditioning. 1
• Consider shorter-acting drugs at bedtime such as guanfacine or clonidine. 1

For Neuropathy-Related Paresthesia

• Implement rehabilitation programs aimed at reducing disability and restoring motor and sensory function. 1
• Prescribe exercise programs including range-of-motion exercises, stationary cycling, walking, and strength training to improve physical fitness and walking ability. 1
• Use antispastic positioning, range of motion exercises, stretching, and splinting for spasticity-related symptoms. 1

Pharmacologic Treatment by Specific Cause

Neuropathic Pain Management

• Anticonvulsants (pregabalin, gabapentin) are first-line agents for neuropathic paresthesia. 1
• Sodium channel blockers (lamotrigine, oxcarbazepine) serve as alternatives. 1
• For paroxysmal kinesigenic dyskinesia, carbamazepine and oxcarbazepine are first-line treatments, but monitor for Stevens-Johnson syndrome. 1

Chronic Pain in Neuropathies

• Encourage mobilization for muscle pain and arthralgia. 1
• Administer medications for neuropathic or nociceptive pain as appropriate. 1
• Consider neurostimulation techniques for persistent cases. 1
• Avoid benzodiazepines like diazepam during recovery, as they may have deleterious effects. 1

Critical Pitfalls to Avoid

• Never overlook medication-induced causes, particularly in patients receiving tuberculosis treatment, opioids, or GLP-1 agonists. 3, 1, 4
• Do not assume all paresthesia is benign—acute onset, rapidly progressive, severe, asymmetric, proximal, or multifocal paresthesia may indicate Guillain-Barré syndrome or vasculitis requiring urgent management. 2
• Monitor patients on carbamazepine closely for serious adverse effects including Stevens-Johnson syndrome. 1
• When paresthesia is associated with predominant motor signs (limb weakness) or severe dysautonomia, expedite evaluation for serious neurologic conditions. 2

Monitoring and Follow-Up

• Regularly assess symptom improvement to determine treatment efficacy. 1
• For diabetic neuropathy, perform comprehensive foot evaluation at least annually. 1
• Monitor for medication side effects, particularly with anticonvulsants and tricyclic antidepressants. 1
• Screen for micronutrient deficiencies (especially vitamin B12) that can cause or worsen paresthesia. 2