Beyond Hives: Chronic Neuropathic Itching

When the discomfort is not all in your head

by Judi Ebbert, PhD, MPH, RN Health Writer

Most of us view pain as the worst kind of suffering. We rarely think of chronic itching as a terrible way to suffer, at least not until we experience it. We have pain scales to measure intensity, but not itch scales. If we did, people with chronic itching would choose the number that most equates with torture. Chronic itching is such a significant problem that a professional organization, the International Society for the Study of Itch (IFSI), comprised of clinicians, researchers, and scientists, is “dedicated to improving our understanding and treatment of pruritus for the benefit of suffering patients worldwide.” Pruritis is the scientific word for severe itching.

Neuropathic itching is itchiness triggered by nerves. The itch feels deep, like it’s under the skin, making the sufferer scratch especially hard. Neuropathic itching is worse than itchiness caused by insect bites and allergic rashes for one reason — those go away. Even though hives (urticaria) can last for many weeks, they will likely go away at some point. Neuropathic itching, however, won’t go away. Worse than that is the fact that it’s common, underrecognized, and often misdiagnosed.

With neuropathic itching, nerves in the upper (cervical) spine, likely compressed by vertebrae, cause the itch sensation. What seems like a skin condition is truly a musculoskeletal defect compressing a nerve to cause relentless deep itchiness. Two common forms of neuropathic itching are notalgia paresthetica and brachioradial pruritus. Both tend to occur in people over age 40. While men and women get brachioradial pruritus, more women than men get notalgia paresthetica.

Notalgia paresthetica, sometimes referred to as the unreachable itch, causes deep intense itching and tingling that feels like pins and needles. The sensations occur in the upper to mid back, often around the shoulder blades. The constant scratching damages the skin, causing hyperpigmentation, or dark patches, in the affected area. The disorder is associated with cervical musculoskeletal disease, particularly at the C4-C6 level of the vertebrae. Other types of paresthetica are cheiralgia (the hand), gonyalgia (the knee and lower leg), meralgia (the upper leg) and even more.

Brachioradial pruritus causes itching and tingling in the skin on one or both arms. It is usually on the mid-arm, but can be on the forearms and upper arms, which typically have marks from constant scratching. The cause may be injury to peripheral cutaneous nerves from sunlight, nerve damage at the level of the cervical spine, or both.

Other forms of nerve-related itching include scars, multiple sclerosis, and more.

How is neuropathic itching diagnosed and treated? Diagnosis is made by a thorough physical examination and medical history. Analysis of the signs and symptoms may be enough to make the diagnosis, but a biopsy may be needed to rule out other clinical causes of itching. An X-ray, CT scan, or MRI of the spine may be taken to determine correctible deformities that could be compressing nerves.

Treatment relieves symptoms for some but not all people. Neither Notalgia paresthetica nor brachioradial pruritus has a definitive cure. The following treatment approaches relieve symptoms for some but not all people. Recommendations of Stumpf and Ständer published in Dermatologic Therapy in 2013 recommend the following treatments:

For notalgia paresthetica, which is especially difficult to treat:

  • Over-the-counter capsaicin applied to the itchy area may provide temporary relief.

  • Prescriptions such as gabapentin, an anticonvulsant, and antidepressants may help.

  • Spinal manipulation to decompress nerves may stop symptoms.

For brachioradial pruritus:

  • Over-the-counter capsaicin applied to the itchy area may provide temporary relief.

  • Topical anesthetics and cooling substances may relieve symptoms.

  • A prescription such as pregabalin, an anticonvulsant, or benzodiazepines (antianxiety drugs such as Xanax) may be helpful.

How can anyone help?

Sufferers benefit from social support because they may not know what they have. And if they know, they are likely frustrated because they realize the itching will never go away.

Awareness of the symptoms gives you the power to help someone identify the reason for their nonstop, unreachable itch. Once they know, they can seek help and try an array of interventions to find temporary relief.

Judi Ebbert, PhD, MPH, RN
Meet Our Writer
Judi Ebbert, PhD, MPH, RN

Judi Ebbert earned her PhD at the University of South Florida’s College of Public Health. She has worked at three NCI-designated comprehensive cancer centers and is a writer/editor at Moffitt Cancer Center. Judi has great interest in chronic disease prevention and treatment, and is an advocate for equitable access to care and optimal quality of life for all people. She loves swimming, her dogs and cats, great food, art, humor, and cinematic thrillers. She’s on Twitter @judithebbert.