Brachioradial Pruritus (BRP)

What is Brachioradial Pruritus (BRP)?

Brachioradial pruritus is  periodic itching of the forearm, arm, and/or shoulder.

There is some thought that there may be a relation between Notalgia Paresthetica and brachioradial pruritus. The recently described association of many cases of brachioradial pruritus( BRP) and cervical spine disease and description of the disease as a possible neuropathic/ neurogenic condition also support a probable neuropathic association of nostalgia paresthetica.  In contrast, NP is usually unilateral while BRP (Brachioradial pruritus) may  involve unilateral or bilateral upper extremities.

During the initial assessment of patients with brachioradial pruritus (BRP) and Notalgia paresthetica, it is important to obtain a thorough past history of osteoarthritis, prior neck trauma, motor vehicle accident, vertebral fracture, cervical neoplasm or malignancy, or cervical disc disease. In the absence of positive medical history, radiographs or MRI of the cervical spine may aid in diagnosis and treatment. Further, a positive family history of osteoarthritis or vertebral disc disease may be contributory. 

Proper management of BRP may involve a multi-specialty cooperative effort of dermatology with radiology, orthopedic surgery, neurology, and adjunctive fields including acupuncture, chiropractic, and physical therapy.

Additional features of the dermatologic condition may include localized burning, pain, tenderness, hyperalgesia, or dysesthesias. BRP tends to be a chronic condition with periodic remissions and exacerbations. While not life threatening and not generally associated with other co-morbidities, it does frequently decrease quality of life causing much discomfort and nuisance to the affected patients.

While to date there has been no uniformly effective treatment, current therapeutic options for BRP include capsaicin cream, eutectic mixture of local anesthetic (EMLA) cream, topical steroids, pramoxine cream, topical cooling, oral steroids, Tiger balm, menthol creams, Cordran tape, intralesional corticosteroid injections, botulinum toxin injections, ¹¹ oral antihistamines, hydroxyzine, doxepin, topamax, anticonvulsant medications, carbamazepine (Tegretol) antidepressant medications, gabapentin (Neurontin), oxcarbazepine, ¹⁴ topiramate, thalidomide ,¹⁰ paravertebral local anesthetic block, ¹⁵ cervical epidural injection, TENS unit, surgical resection of the rib, and many others. Some of the current systemic therapies may in fact exert their effect through the spinal nerves and central nervous system thereby supporting the neuropathic etiology of BRP( Brachioradial Pruritus).

A study by Wallengren et al from Sweden published in the Archives of Dermatology in 2001 demosntrated the effectiveness  of cutaneous field stimulation in NP and BRP patients. Their study showed a reduction in itching accompanied by degeneration of the epidermal nerve fibers, as evidenced by the loss of protein gene product 9.5 immunoreactivity.. ²³

In the future, first line therapy for BRP and notalgia paresthetica (NP) with associated cervical disease may include non-dermatologic, non-invasive treatments such as spinal manipulation, physical therapy, cervical soft collars, massage, cervical traction, cervical muscle strengthening and increased range on motion, cervical discectomy with fusion, oral non-steroidal anti-inflammatory medications (ibuprofen, celecoxib,  ketoralac), TENS units,  and oral muscle relaxants (carisoprodal, cyclobenzapril, methocarbamol, metaxalone). Other measures for degenerative disc disease as introduced may also be considered.

BRP (brachioradial pruritus) may not be solely a skin disease per se but a cutaneous sign of an underlying degenerative cervical spine disease. The striking association of BRP with degenerative or traumatic cervico-thoracic spine disease suggests that early spinal nerve impingement may contribute to the pathogenesis of this skin symptoms of the disease. Additional studies are needed to further assess the relationship of BRP with cervical spine disease. Whether this is a causal or coincidental finding remains to be determined in larger studies. While topical therapies may in some cases seemingly help decrease the localized symptoms in BRP, systemic or broader scope spinal evaluation may be warranted to fully evaluate refractory cases. Cervical spinal imaging and treatment may be appropriate as primary or first line therapy in many cases of BRP.