Clinical Challenge: Itching and Burning on the Arm - MPR

Clinical Challenge: Itching and Burning on the Arm

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A 57-year-old woman presents with complaints of intense itching and burning affecting her left arm. The itch waxes and wanes in intensity with flares increasing in the summer months, particularly following sun exposure. Application of ice to the area affords temporary relief. The patient has tried a variety of medicated creams that have not been effective. Her medical history is significant for fibromyalgia and cervical disk herniation. Physical examination reveals mottled pigmentary changes on her left arm without evidence of excoriation or lichenification.

The patient was diagnosed with brachioradial pruritus (BP), a type of chronic localized neuropathic itch that commonly presents on the upper arms, elbows, and forearms with or without evidence of scratching.1 The etiology of this entity is uncertain; pathogenesis has been...

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The patient was diagnosed with brachioradial pruritus (BP), a type of chronic localized neuropathic itch that commonly presents on the upper arms, elbows, and forearms with or without evidence of scratching.1 The etiology of this entity is uncertain; pathogenesis has been linked to several factors including previous cervical spine or rib injury, as well as sun exposure.2

A significant number of patients diagnosed with BP have a history of neck trauma or degenerative arthritis, suggesting that nerve injury to the cervical spine or nerve compression in other areas may serve as a contributing factor for BP.2 Additionally, exposure to ultraviolet light in the warmer months may exacerbate this condition; colder weather has been associated with periods of remission.3  BP is more common in women aged 20 to 80 years.4

The diagnosis of BP is based on history and the paucity of clinical findings. Pruritus is often severe. One characteristic finding of BP is the “ice pack sign,” a subjective finding in which cooling the skin with an ice pack is the only modality that provides relief from itch.5

Nonsteroidal anti-inflammatory drugs, sunscreen, topical capsaicin, topical corticosteroids, carbamazepine, amitriptyline, and acupuncture are some of the various treatment modalities described for management of BP with varying degrees of success.  Gabapentin has shown promise in the treatment of centrally mediated pruritic syndromes.6

Treatment strategy notwithstanding, evidence shows that shorter duration of treatment is associated with lower response rates, suggesting the need for chronic medical management of BP.7  A study conducted by Weinberg et al found that relief was provided to 3 patients by  transforaminal epidural steroid injections into the cervical spine performed using computed tomography guidance.8

Nelson Maniscalco, DPM, is a joint podiatry/dermatology fellow under the aegis of St. Luke’s Medical Center in Allentown, Pennsylvania, and the DermDox Center for Dermatology. Stephen Schleicher, MD, is director of the DermDox Center for Dermatology, associate professor of medicine at Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.

Reference

Oaklander A. Neuropathic itch. In: Carstens E, Akiyama T, eds. Itch: Mechanisms and Treatment. CRC Press/Taylor & Francis; 2014:89-118.

2. Wallengren J. Self-healing photo-neuropathy and cervical spinal arthrosis in four sisters with brachioradial pruritusJ Brachial Plex Perioher Nerve Inj. 2009;4:21.

3. Weisshaar E, Kucenic MJ, Fleischer Jr AB. Pruritus: a reviewActa Derm Venereol Suppl (Stockh). 2003;83(213):5-32.

4. Masuda PY, Martelli ACC, Wachholz, PA, Akumatsu HT, Martins AL, Silva NM. Brachioradial pruritus: descriptive analysis of Brazilian case seriesJ Dtsch Dermatol Ges. 2013;11(6):530-535.

5. Beuscher L, Reeves G. Brachioradial pruritus: approach to the patient with enigmatic forearm pruritusNurs Pract. 2012;8(9):736-741.  

6. Yilmaz S, Ceyhan AM, Akkaya VB. Brachioradial pruritus successfully treated with gabapentinJ Dermatol. 2010;37(7):662-665.

7. Berger AA, Urits I, Orhurhu V, Viswanath O, Hasoon J. Brachioradial pruritus in a 52-year-old woman: a case report. Case Rep Womens Health. 2019;24:e00157.

8. Weinberg BD, Amans M, Deviren S, Berger T, Shah V. Brachioradial pruritus treated with computed tomography-guided cervical nerve root block: a case seriesJAAD Case Rep. 2018;4(7):640-644.