Notalgia paresthetica: cause, symptoms and treatment

Notalgia paresthetica is a common form of itching in the shoulder blades. It mainly occurs in men and women between the ages of 40 and 80. Itching is the main complaint of notalgia paresthetica. You may also suffer from other symptoms such as burning, pain, hypersensitivity, increased pain sensation and increased skin sensitivity. Effective treatment of notalgia paresthetica is difficult. The first choice is capsaicin ointment (so-called ‘pepper ointment’). This exhausts the nerves, so that pain or sensory stimuli are no longer transmitted to the brain. Notalgia paresthetica was first described in the medical literature in 1934 by Astwazaturow.

  • What is notalgia paraesthetica?
  • Cause of notalgia paresthetica
  • Who gets it?
  • Risk factors
  • Symptoms of notalgia paresthetica
  • Itching, pain and burning
  • Skin changes (brown spot)
  • Course
  • Examination and diagnosis
  • Treatment of notalgia paresthetica
  • Ointment
  • Amitriptyline
  • Avoid scratching
  • Complications
  • Prevention
  • Prognosis

Notalgia paresthetica / Source: Maroliver, Wikimedia Commons (CC BY-SA-4.0)

What is notalgia paraesthetica?

Notalgia paresthetica is a common form of itching on the back near the shoulder blades. It mainly occurs in adults aged 40-80 years. Severe forms of notalgia can be very distressing and negatively affect quality of life.

Cause of notalgia paresthetica

Although the etiology of notalgia paresthetica is still unclear in 2023, it is suspected that a number of possible mechanisms may underlie it. It is thought that the itching may occur due to damage to the sensory nerves in the skin that come from the spinal cord. It is possible that the sensory nerves involved are extra vulnerable to external influences, such as shingles, due to their specific anatomical situation. Abnormalities of the spine may also provide an explanation, as a significant proportion of patients with notalgia have been diagnosed with a spinal problem.

Who gets it?

Notalgia paresthetica can occur at any age, but is more common in people aged 40-80. Both men and women can get it, although the condition is more common in middle-aged women. Notalgia paresthetica occurs worldwide in all ethnic groups.

Risk factors

The risk factors for notalgia paresthetica are the following:

  • Muscle spasms in the back
  • Cervical osteoarthritis
  • Trauma to the neck area
  • Car or sports accident with injuries such as whiplash
  • Excessive weight lifting

Certain professions are known to increase the risk, such as hairdressers and painters.

Symptoms of notalgia paresthetica

Itching, pain and burning

Itching is the main complaint of notalgia paresthetica. You may also suffer from burning, pain, hypersensitivity, increased pain sensation (hyperalgesia) and reduced or increased skin sensitivity (dysesthesia).

Skin changes (brown spot)

Skin changes may occur as a result of scratching. What you can then see is an annoyingly itchy unilateral blurred pink to hyperpigmented (brown) spot on one of the shoulder blades, usually 3-10 cm in size.

Course

The condition has a chronic course with temporary reduction or disappearance of disease symptoms (remissions) and sudden worsening of the disease symptoms (exacerbations). Sometimes the condition disappears after months or years, only to flare up again.

Examination and diagnosis

Physical examination
The diagnosis of notalgia paresthetica is often made visually. A skin biopsy is generally not necessary. The condition is common and likely underdiagnosed.

Lichen simplex chronicus on the elbow / Source: Eyon, Wikimedia Commons (CC BY-SA-3.0)

Differential diagnosis
The condition should not be confused with:

  • a reaction from a bite from an arthropod (insect bite)
  • atopic eczema
  • allergic contact dermatitis
  • brachioradial pruritus or itching
  • allergic contact dermatitis
  • dry skin
  • herpes zoster or shingles
  • lichen simplex chronicus
  • macular amyloidosis
  • parasite or infestation delusion
  • post-inflammatory hyperpigmentation
  • prurigo nodularis
  • tinea corporis
  • pityriasis versicolor or tinea versicolor
  • toxicoderma

Treatment of notalgia paresthetica

Ointment

Effective treatment is difficult for notalgia paresthetica. The first choice is capsaicin ointment (‘pepper ointment’). The active ingredient (capsaicin) gives the sharp taste to red chili pepper. Capsaicin prevents pain or sensory stimuli from being transmitted to the brain by actually causing a kind of nerve exhaustion. Other substances that may have (some) effect are:

  • lidocaine ointment
  • corticosteroid ointment
  • cooling ointments or lotions

Amitriptyline

In severe cases, amitriptyline may be prescribed at night. This medication is used for depression, but in low doses it appears to have a mainly analgesic and relaxing effect. Taken at night, it can ensure a better night’s sleep, which in turn has a good effect on the complaints.

Avoid scratching

Try to stay off the skin as much as possible. Scratching or rubbing the area increases the itching and can lead to skin changes.

Complications

No significant complications due to notalgia paresthetica are reported in the literature. Chronic itching and flaking of the skin can cause the skin to become thick, discolored and leathery. Excessive scratching can lead to skin ulcers. Stress can occur due to notalgia paresthetica, which affects your performance at school, university and work.

Prevention

In 2023, there are no specific methods or guidelines to prevent notalgia paresthetica, which is caused by genetic factors. However, some of the risk factors can be controlled, for example:

  • Avoidance of excessive weight lifting;
  • Taking adequate safety and health precautions while carrying out certain work;
  • Prevent whiplash injuries by using the correct sports equipment and wearing seat belts.

Prognosis

The prognosis of notalgia paresthetica is excellent with proper treatment, but it also depends on the severity of the symptoms. The condition can also affect the quality of life and cause stress, sometimes resulting in depression. People with milder symptoms generally have a better prognosis than people with severe symptoms. Symptoms may recur in up to 40% of cases, and therefore careful follow-up is needed.

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