Case Report
A 74-year-old man presented with persistent episodes of severe pruritus with exacerbations on the bilateral forearms, arms, and left side of the mid back of 4 years’ duration. He had a refractory and debilitating disease that had failed extensive therapies including topical antipruritics, antihistamines, oral hydroxyzine, capsaicin, potent topical steroids (ie, clobetasol, fluocinonide, triamcinolone), phototherapy with narrowband UVB, and various dietary modifications including a gluten-free trial. The patient reported he had exhausted all medical evaluation through care with more than 7 physicians and multiple dermatologists, including a university-based dermatology department for repeated consultations; he was seen by our dermatology center for an eighth opinion.
Initial dermatologic examination revealed multiple secondarily excoriated, hemorrhagic, hyperpigmented plaques and nodules on the right side of the mid upper back indicative of notalgia paresthetica (NP) with secondary chronic skin changes (Figure 1). Additional examination of the left arm and forearm revealed several open erosions, raised nodules, and lichenified skin plaques indicative of brachioradial pruritus (BP) with secondary skin changes (Figure 2). In addition, multiple lichenified plaques of the left side of the mid back were associated with decreased sensory alternations to light touch and pin prick. Of note, the localized pruritus pattern, particularly of the unilateral infrascapular back region, heralded the possibility of a neuropathic pruritus condition originating from the cervical spine. Examination confirmed decreased range of motion in the neck with associated marked palpable bilateral cervical muscle spasm and tenderness. Laboratory testing confirmed Staphylococcus aureus secondary skin infection that was treated empirically with chlorhexidine wash. General pruritus serology and imaging workup was ordered with contributory results. The patient’s medical history was notable for noninsulin-dependent diabetes mellitus, obesity, deep venous thrombosis, asthma, vein surgery, cardiovascular disease, atrial fibrillation, atopy, allergies, asthma, and keratosis pilaris, as well as drug intolerances of warfarin sodium, sitagliptin, and clopidogrel. His medications on presentation included glyburide, digoxin, prednisone, aspirin, cetirizine, cimetidine, and hydroxyzine. Based on the relatively classic localized pruritus symptoms and the anatomical distribution of skin findings, a clinical diagnosis of concurrent NP and BRP was made, and radiologic studies of the cervical spine were ordered.
Figure 1. Notalgia paresthetica of the right side of the mid back (classic distribution) with atypical hyperpigmented presentation on the right side of the mid upper back.
Figure 2. Brachioradial pruritus of the left arm with excoriations, lichenification, and prurigo nodules.
Magnetic resonance imaging (MRI) of the cervical spine showed severe central canal stenosis at C3-C4 secondary to disc disease slight asymmetric toward the right side, severe central canal stenosis at C4-C5 slightly more prominent in the midline, severe central stenosis at C5-C6 more prominent in the midline, and mild changes at other levels as described. Laboratory workup revealed an abnormal complete blood cell count with mildly elevated white blood cell count (11,800/µL [reference range, 4000–10,500/µL]), elevated neutrophils (8600/µL [reference range, 1800–7800/µL]), elevated eosinophils (600/µL [reference range, 0–450/µL ]), and elevated IgE (160 IU/mL [reference range, 0–100 IU/mL]). Further testing revealed negative results for Helicobacter pylori IgG and IgM, human immunodeficiency virus, and hepatitis B and C screening panels; antinuclear antibody negative; normal thyroid-stimulating hormone; and normal thyroid peroxidase antibody. Chest radiograph and computed tomography of the chest, abdomen, and pelvis were negative.
We referred the patient for a neurosurgical consultation that uncovered newly diagnosed severe cervical stenosis with mild to moderate canal compromise at C3, C4, C5, and C6. His motor examination revealed full strength in the upper extremities (5/5). Sensory examination showed patchy sensory alteration on the mid back. He declined oral antibiotics as advised for the skin staphylococcal infection and neurosurgical treatment for the cervical disease.
During the 4 years prior to presentation at our center, the patient reported failure to improve with a dermatologically prescribed gluten-free diet as well as all topical and oral steroid treatments. He was presented at a university grand rounds where a suggestion for UVB light treatment was made; the patient reported possible worsening of symptoms with narrowband UVB phototherapy.
At the patient’s first visit at our center, for immediate symptom relief he underwent therapy with transcutaneous electronic nerve stimulation (TENS) with acupuncture of the cervicothoracic spine (Figure 3). He agreed to discontinue oral prednisone and begin chlorhexidine cleansing body wash, low-dose hydroxyzine 10-mg tablets up to 60 mg every 6 hours as required for pruritus, and mupirocin intranasal ointment. At 1-week follow-up, he reported at least 50% improvement in his symptoms with decreased pruritus, improved sleep, and enhanced quality of life. Within 2 weeks of initial assessment, there was a notable 70% clinical improvement of both the NP and BRP, with a notable decrease in cutaneous erosions and flattening of the pruritic skin nodules. He reported adequate control of symptoms with continued TENS for at-home use 3 times daily for 5- to 10-minute intervals.
Figure 3. Transcutaneous electronic nerve stimulation treatment electrodes on the back.