Treatment of notalgia paraesthetica with an 8% capsaicin patch

MADAM, Two patients with severe pruritus on the upper back were referred to our outpatient pruritus clinic. The first patient, a 73-year-old woman, was diagnosed with an atypical form of notalgia paraesthetica (NP) presenting with prurigo nodularis-like skin lesions in two symmetrical paravertebral hyperpigmented maculae with intense itching (Fig. 1a). An X-ray revealed a herniated vertebral disc in the cervical spine, matching the affected dermatomes. The second patient was a 61-year-old woman with NP complaining of intense itch located in the right mid-scapular region. She presented with a hyperpigmented, mildly erythematous macula in the area of the pruritus. Radiological examination revealed kyphosis and spondylitis of the thoracic spine. Both patients had multiple previous topical and systemic treatments. We decided to treat both patients for 60 min with Qutenza (NeurogesX, Inc., San Mateo, CA, U.S.A.), an 8% capsaicin patch. The first patient tolerated the patch for only 20 min because it became too painful. The second patient tolerated the patch well, with a mild to moderate burning sensation throughout the application time and for a further 30 min. Capsaicin treatment is known to lead to stinging and burning, therefore the area of contact with the 8% capsaicin patch has to be pretreated with EMLA (AstraZeneca, London, U.K.). The most likely reason for the painful sensation in the first patient is that there were some erosive lesions in the pruritic areas. Although we anticipated that this could be a limiting factor (and informed the patient accordingly), the patient was willing to proceed. After removal of the patch, pruritus was considerably decreased in both patients (Figs 1b and 2a). While pruritus returned within a few days to almost maximum itch intensity in the first patient, the second patient stayed completely free of any itching sensation (Fig. 2a) and 8 weeks after the treatment, the macula on the back was visibly less pigmented and less erythematous (Fig. 2b, c). Currently, the patient is 12 weeks post-treatment and is still free of any symptom. Chronic pruritus is a major therapeutic problem and can severely impact quality of life. Depending on the underlying cause, itch can have many different qualities, different time courses and can be generalized or localized. A typical form of localized chronic pruritus is neuropathic pruritus as seen for example in NP or brachioradial pruritus. NP results from nerve entrapment of the posterior rami, usually of spinal nerves arising at T2–T6. Patients usually complain of severe unilateral pruritus on the mid or upper back, often, but not always, associated with a hyperpigmented patch in the affected area. Often, degenerative changes and other vertebral pathologies such as a herniated nucleus pulposus can be found. Currently, there is no evidence-based therapeutic approach for the treatment of NP or other forms of localized chronic pruritus. Treatment strategies include neurosurgical and orthopaedic approaches, systemic therapy with gabapentin and topical therapy with local anaesthetics, corticosteroids or capsaicin. Although topical capsaicin has been shown to improve itching in some patients with NP, there are several limitations to this treatment: (i) it needs to be repeated 5–6 times daily; (ii) it may stain clothes and bedding; and (iii) great care has to be taken not to rub fingers in the face, nose or eyes after application of the cream. Here, we report two cases of localized pruritus treated with a single application of an 8% capsaicin patch. A single applica(a)