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JEADV 2007, 21, 1413–1450 Journal compilation © 2007 European Academy of Dermatology and Venereology

MP Loosemore,*† JS Bordeaux,‡ JD Bernhard‡

 

Gabapentin treatment for nostalgia paresthetica, a common isolated peripheral sensory neuropathy

Editor

Notalgia paresthetica (NP) is a common, albeit infrequently

reported, isolated peripheral sensory neuropathy. It is a

model example for a number of neurogenic/neuropathic

itches.1 NP is characterized by pruritus on the back that

may be associated with paresthesia, hypesthesia, or pain.

It is usually, but not always, asymmetrical and tends to

occur within the distribution of spinal nerves T2-T6.2

Current therapies for this condition are not always

effective. Here, we report the case of a patient with NP

that was responsive to treatment with gabapentin.

An 82-year-old man was referred for evaluation of an

intense, severe burning itch located in the mid-scapular

region of the upper back in November 2003. He also noted

itching localised to the extensor aspects of both arms. His

medical history was significant for spinal stenosis, status

post-corrective surgery in June 2003. The itch developed

after the surgery. He denied any constitutional symptoms.

Physical exam was unrevealing. CBC with differential,

basic metabolic panel, thyroid-stimulating hormone, and

chest X-ray were all normal, save for a slight normocytic

anaemia. A diagnosis of NP with coincidental brachioradial

pruritus (BRP) was made, and he was given hydrocortisone/

pramoxine (2.5%) ointment for symptomatic relief.

He returned in December 2003 without improvement. At

this time, he was offered treatment with capsaicin but

declined additional topical therapy. Instead, he requested

‘pills’ to treat his condition. He was given gabapentin

(300 mg) to take at bedtime. After 1 month of treatment,

the scapular itch improved, and his arm itching was gone.

Gabapentin was increased to 600 mg at night. In May

2004, he called and stated that the itch had completely

resolved until he ran out of gabapentin, at which point the

pruritus returned to its original severe intensity in the

scapular area only, consistent with isolated NP. He was restarted

on gabapentin (600 mg) at night, and once again,

the pruritus resolved. He again stopped the medication in

October 2004, only to have the itch return once more.

Gabapentin, at 600 mg nightly, was prescribed, and the

pruritus cleared again. As of April 2005, he continued to

be free of itching on 600 mg gabapentin at night.

Recent evidence implicates dorsal spinal nerve impingement

or injury in the pathogenesis of NP.3 Given its presumed

neural origin, many of the treatments for NP are thought

to work at a neuronal level. Topical corticosteroids are

generally ineffective unless secondary inflammation is

present. Corticosteroids do stabilize membranes and contribute

to suppression of ectopic neural pacemaker activity;

thus, it is not entirely unreasonable to hope that they may

be helpful in some cases.4 Topical capsaicin depletes neuropeptides

from the unmyelinated C-fibre polymodal

nociceptors that transmit the pruritic sensation from the

skin to the central nervous system.5,6 Capsaicin has been

shown to be helpful, but symptoms tend to recur after discontinuation.

5 Given the discomfort it causes and the

need for repeated application, this form of therapy, like all

topicals, can engender patient non-compliance. Oral therapy,

as shown in this case, may be preferred by some patients.

Gabapentin is an anticonvulsant that has been used to

treat neuropathic pain.7 It has been described as a therapy

for BRP,8,9 a pruritic condition of the extensor aspects of

the arms very similar to NP and also linked to nerve

injury.10 It is not an entirely surprising coincidence that

this patient initially had symptoms of both conditions.

Gabapentin has a wide therapeutic dose range with mild

to moderate side-effects, including sedation, dizziness,

nausea, and gastrointestinal upset.7 Neuropathic pain is

normally treated by starting at a 300 mg daily dose and

titrating up to 900 mg per day,7 which would seem to be

a reasonable approach to treat neuropathic itch. Gabapentin

has been safely dosed to a maximum of 3600 g per day.7

The effect of oral gabapentin in the treatment of this

patient is encouraging and may be worth considering in

severe cases of NP.

References

1 Bernhard JD. Neurogenic pruritus and strange skin

sensations. In: Bernhard JD, ed. ITCH. Mechanisms and

Management of Pruritus. McGraw-Hill , New York , 1994:

185–201.

2 Massey EW, Pleet AB. Localized pruritus-notalgia

paresthetica. Arch Dermatol 1979; 115: 982–983.

3 Savk O, Savk E. Investigation of spinal pathology in

notalgia paresthetica. J Am Acad Dermatol 2005; 52:

1085–1087.

4 Devor M, Govrin-Lippman R, Raber P.

Corticosteriods suppress ectopic neuronal discharge

originating in experimental neuromas. Pain 1985; 22:

127–137.

5 Wallengren J, Klinder M. Successful treatment of notalgia

paresthetica with topical capsaicin: vehicle-controlled,

double-blind, crossover study. J Am Acad Dermatol 1995; 32:

287–289.

6 Lowitt MH, Bernhard JD. Pruritus. Semin Neurol 1992; 12:

374–384.

7 Backonja M, Glanzman RL. Gabapentin dosing for

neuropathic pain: evidence from randomized, placebocontrolled

clinical trials. Clin Ther 2003; 25: 81–104.

8 Bueller HA, Bernhard JD, Dubroff LM. Gabapentin

treatment for brachioradial pruritus. J Eur Acad Dermatol

Venereol 1999; 13: 227–228.

9 Winhoven SM, Coulson IH, Bottomley WW. Brachioradial

pruritus: response to treatment with gabapentin.

Br J Dermatol 2004; 150: 786–787.

10 Cohen AD, Masalha R, Medvedovsky E, Vardy DA.

Brachioradial pruritus: a symptom of neuropathy.

J Am Acad Dermatol 2003; 48: 825–828..

DOI: 10.1111/j.1468-3083.2007.02256.x

 

 

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