50 year old man with a red patch on his back? Otherwise healthy.
What is your diagnosis?
Diagnosis:
Notalgia Paresthetica
Notalgia paresthetica is a curious condition that produces a very pruritic patch located on the upper central back just off center of the spine usually near the scapula. I was attending a conference several years ago and notalgia paresthetica was one of the discussion topics. Out of curiosity, the lecturer asked how many dermatologists in the audience suffered from this condition and to my surprise; approximately 15% of the audience raised their hand. The exact cause in every case is uncertain; however, research indicates that in many cases the itching is produced by sensory nerve irritation as it turns sharply and enters the spinal canal (see JAAD reference below).. This mild irritation produced the classic pruritus seen in the area. This particular case is rather fascinating. This is a patient I saw when I was a dermatology resident at the VA Hospital in Minneapolis. The patient actually made an appointment because of the condition; however, as he was waiting in the reception area, it was itching him so severely, he used one of his pens to scratch and rub the area. As a result, when I saw him clinically, the rubbing from his pen had clearly and remarkably delineated the exact area of notalgia paresthetica. In general, notalgia paresthetica has no cutaneous manifestations, but fortunately, for the instruction of this case, he was happy to, indirectly, by rubbing his back with the pen, show us exactly the classic location of the condition. In chronic conditions, the area can become lichenified and hyperpigmented.
Notalgia paresthetica is primarily a nuisance that can be relieved with an inexpensive back scratcher (or in this case, a handy pocket pen). There have been reports of the successful use topical Capsaicin and other topical anesthetic preparations and also Botox injections in the area.
In cases where the 3 dollar back scratcher isn’t working for satisfactory relief, I have found that I have very good success treating the area with topical doxepin (Zonalon) cream. This can be applied four to six times daily to the affected areas. I have the patient use a Bendable Body Wand lotion applicator to apply the Zonalon cream. We carry a supply of these at our office that we pass on to patients at our cost. Or they can be ordered by the patient at www.lotionapplicators.com. (I have no conflict of interest here).
These wands work very well for the application of a variety of medicines and persons who live alone and teenagers seem to be particularly appreciative of a method of applying medications to their back independently with relative ease.
Charles E. Crutchfield III, MD
Clinical Adjunct Associate Professor of Dermatology
At the
University of Minnesota Medical School
Medical Director, Crutchfield Dermatology
www.CrutchfieldDermatology.com
For additional information from an article in JAAD, please Google: “JAAD nostalgia paresthetica spinal” or view this JAAD online article: www.eblue.org/article/S0190-9622(05)00496-2/pdf
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