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
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J Am Acad Dermatol 2003; 48: 825–828..
DOI: 10.1111/j.1468-3083.2007.02256.x