Notalgia Paresthetica

Notalgia paresthetica is a nerve disorder that causes intense itching, burning, or tingling in a specific patch of skin on your upper back, usually between your shoulder blade and spine. Although it can be uncomfortable and frustrating, the condition is not dangerous to your health.

Table of contents

• What is notalgia paresthetica?
• What causes this condition?
• Who is affected?
• Signs and symptoms
• How is it diagnosed?
• Treatment options
• Living with the condition

What is notalgia paresthetica?

Notalgia paresthetica is a condition that affects the nerves in your upper back, creating uncomfortable sensations in the skin. The name comes from Greek words: “notalgia” means “pain in the back,” and “paresthetica” refers to burning pain, tingling, or itch^[1].

This condition is also called thoracic cutaneous nerve entrapment syndrome. It typically affects a small area of skin on the medial border (inner edge) of one shoulder blade, usually between the second and sixth thoracic vertebrae (the bones in your mid-back labeled T2 to T6)^[2]. The symptoms can last for months or even years^[1].

The condition was first described by Russian neurologist Michail Astwazaturow in 1934 and is generally considered harmless^[2].

G60.8

Thoracic nerve entrapment, Hereditary localized pruritus, Posterior pigmented pruritic patch, Subscapular pruritus

What causes this condition?

Researchers are not completely certain about what causes notalgia paresthetica. Most experts agree that it is a type of neuropathy (a condition caused by nerve damage or malfunction), but they debate whether the problem starts at the spine or in the skin nerves themselves^[1].

The most common explanation is that nerves in your upper back become irritated or compressed. The nerves that supply sensation to this area of skin emerge from the spinal cord at the thoracic segments T2 through T6. These nerves must travel a long path through the thick muscles of your back, and they make a right-angled turn before reaching the skin^[3]. This unusual angle may make them more vulnerable to compression or injury from muscle movements^[2].

Several conditions can lead to nerve irritation or damage in this area^[1]:

• Degenerative disk disease in the spine
• Herniated or “slipped” disc
• Osteoarthritic changes in the spine
• Back injury or trauma
• Muscle spasms in the back muscles
• Shingles (herpes zoster infection)
• Certain metabolic conditions, such as type 2 diabetes
• Poor posture, especially from prolonged sitting at workstations

Studies have found a strong association between notalgia paresthetica and cervical (neck) spine disease. Many patients with this condition have degenerative changes or herniated discs in their neck, particularly at the C5-C6 level^[4]. Even when imaging tests don’t show spine problems, many patients recall a history of neck injury, whiplash, or chronic neck muscle tension^[9].

When nerves are compressed or irritated, they may send incorrect signals to your brain, making you feel itching or pain even when there is no actual problem with your skin^[1].

Who is affected?

Notalgia paresthetica is thought to be relatively common, though the exact frequency is unknown because the condition is often underdiagnosed^[1]. Chronic itchy skin (pruritus) affects more than 20% of people at some point in their lives. Notalgia paresthetica represents approximately 8% of all cases of chronic pruritus^[1].

The condition mainly affects adults, especially people over 50 years of age. It occurs more commonly in women than in men^[1]. Some studies report that women represent 62 to 87% of cases^[2].

The condition typically affects only one side of the back. Interestingly, it more commonly appears on the side opposite to a person’s dominant hand^[2]. This means right-handed people often experience symptoms on the left side of their back, which they can reach more easily to scratch.

Notalgia paresthetica is rare in children. If it occurs in young children, it may be a sign of a rare inherited condition called multiple endocrine neoplasia type 2A (MEN 2A)^[1].

Signs and symptoms

The main symptom of notalgia paresthetica is intense itching in a small patch of skin on your upper back, between the inner part of your shoulder blade and your spine. The itch usually affects only one side of your back, though it can occasionally affect both sides^[1].

The itch may be intermittent or continuous. It is often unrelieved by scratching, although scratching and rubbing may feel temporarily pleasurable^[3]. The affected area may sometimes spread to include both shoulder blades or extend more widely over the back and shoulders^[3].

Other sensations that may occur in the same area include^[1]:

• Tingling or “pins and needles” feeling
• Numbness
• Burning sensation
• Pain
• Tenderness to touch
• Feelings of heat or cold
• Increased sensitivity to touch (hyperesthesia)

An important feature of notalgia paresthetica is that it does not begin with a rash. It is a nerve problem, not a primary skin condition^[1]. However, because the itch is so intense and difficult to resist, most people scratch or rub the area constantly. Over time, this can cause visible changes to the skin^[3]:

• Discolored patch (often brown or darker than surrounding skin) from chronic rubbing
• Scratch marks
• Hyperpigmentation (darkened areas)
• Hypopigmentation (lightened or white marks)
• Thickened skin (lichen simplex, a type of eczema)
• Scarring
• Lumps or bumps
• Bleeding or scabbing

The condition often starts after a period of intense exercise that causes muscle stiffness, or after a period of inactivity. Some people can recall a specific back or neck injury before symptoms began^[3].

Research with patients living with notalgia paresthetica has shown that the condition significantly affects quality of life. The persistent itch frequently impacts mood, interferes with sleep, and disrupts daily self-care activities^[17].

How is it diagnosed?

Healthcare providers typically diagnose notalgia paresthetica based on your medical history and a physical examination. The diagnosis is largely clinical, meaning it relies on the pattern of symptoms you describe and what the doctor observes during examination^[1].

During the visit, your healthcare provider will ask about^[1]:

• Your symptoms and when they started
• Your medical history, including any spine problems, injuries, or conditions like diabetes
• Current medications you are taking
• Any history of neck trauma, whiplash, or back injury

The provider will perform a physical examination of your back and may test the sensation in the affected area using pinprick, light touch with cotton wool, or temperature tests. There may be reduced sensation, increased sensitivity, or altered response to these tests. Some patients also have reduced or absent sweating in the affected area^[3].

Providers rarely order medical tests such as imaging or blood tests to diagnose notalgia paresthetica. They typically only request these if you have additional symptoms that suggest a neurological or neuromuscular condition^[1].

When imaging is performed, X-rays, CT scans, or MRI of the spine may show degenerative changes in the vertebrae or a herniated disc in the area that corresponds to the affected skin. However, in many cases, no abnormality is found on these tests^[3]. Research has shown that many patients with notalgia paresthetica have cervical spine changes, particularly at the C6-C7 segment^[9].

If a skin biopsy is performed, it will usually be reported as normal unless there is secondary dermatitis from scratching^[3].

Treatment options

Notalgia paresthetica can be difficult to treat. There is a wide range of treatment options available, but they have varying levels of success. What helps one person may not help another^[1]. Treatment is not always necessary, and it is not always successful^[3].

An important shift has occurred in how this condition is approached. Rather than focusing only on treating the skin symptoms, many experts now recommend addressing the underlying spine and nerve issues as first-line therapy^[12].

Treatments targeting the spine and muscles

Because notalgia paresthetica is often associated with neck and spine problems, treatments that address musculoskeletal issues may be helpful^[12]:

• Physical therapy with exercises and stretches for the upper back and neck
• Chiropractic care or spinal manipulation
• Massage therapy
• Cervical traction
• Postural correction and ergonomic adjustments
• Transcutaneous electrical nerve stimulation (TENS)
• Electrical muscle stimulation (EMS)
• Acupuncture

Physical therapy exercises that have been reported as effective include^[3]:

1. While sitting, cross your arms and bend forward to stretch the upper back
2. With arms at your sides, raise your shoulders and rotate them forwards and backwards
3. With arms straight, rotate them forwards 360 degrees and then backwards 360 degrees
4. Rotate your upper body left and right until you feel a stretch, then hold
5. Massage the muscles beside the spine in the affected area

One study showed that intradermal (within the skin) lidocaine injections provided significant relief of both pain and itching in patients with notalgia paresthetica, with improvement lasting up to three months^[9].

Topical treatments applied to the skin

Various creams and lotions may provide some relief, though results are often limited^[3]:

• Cooling lotions or creams containing camphor and menthol
• Capsaicin cream, which depletes nerve endings of their chemical transmitters (requires frequent application and may cause burning or stinging)^[5]
• Local anesthetic creams for temporary symptom relief
• Topical corticosteroids to treat any associated lichen simplex (skin thickening from scratching)

It is important to note that antihistamine or steroid creams do not typically provide lasting benefits^[2].

Oral medications

Several medications taken by mouth may help control nerve-related symptoms^[3]:

• Gabapentin or pregabalin (medications for neuropathic pain)
• Amitriptyline or other tricyclic antidepressants taken at night to help with sleep and counteract nerve symptoms
• Oxcarbazepine (an anticonvulsant medication)

Oral medications that target nerve function, particularly gabapentin, are reported to be among the most effective therapies for this condition^[2].

Other treatment approaches

Other treatments that have been tried with varying success include:

• Botulinum toxin injections (though one study found this was not effective)^[3]
• Paravertebral nerve blocks with medication injected near the spine^[5]
• In rare cases, surgical decompression of compressed spinal nerves

Self-care and home remedies

Several self-care measures may help manage symptoms:

• Apply ice packs to the affected area
• Improve workstation ergonomics to reduce postural stress
• Adjust sleep position
• Avoid clothing or bra straps that put excessive pressure on the area
• Practice good posture throughout the day
• Perform regular stretching exercises for the upper back and chest

Living with the condition

Notalgia paresthetica is a chronic condition that tends to have periodic remissions (when symptoms improve) and exacerbations (when symptoms worsen)^[4]. While it is not life-threatening and is generally not associated with other serious health problems, it can have a significant impact on quality of life and cause considerable discomfort^[4].

The condition is not curable in the traditional sense, but it is controllable with proper management^[4]. Many people find that simply understanding that their persistent itch has a medical explanation provides some comfort^[13].

Treatment of underlying neck or spine problems by non-skin-focused approaches often results in improvement of symptoms. This suggests that addressing the root cause—nerve irritation from musculoskeletal issues—is more effective than only treating the skin^[4].

Research has shown that at the time of evaluation, most patients with notalgia paresthetica are not receiving any treatment for their condition^[17]. This highlights that there remains an unmet need for effective therapeutic options and greater awareness of this condition among both patients and healthcare providers.