Brachioradial Pruritus: An Etiological Review and Treatment Summary

Abstract Title: Brachioradial Pruritus: An Etiological Review and Treatment Summary

Background: Brachioradial pruritis (BRP) is a relatively uncommon neuropathic dysesthesia which can cause patients with this condition a significant amount of pain and suffering.  It presents as an unrelenting itching, burning, tingling, or stinging sensation localized to the dorsolateral upper extremities. There is no identifiable cause of BRP to date although it is thought to be secondary to either cervical spine pathology or exposure to ultraviolet radiation (UVR). Not only is the cause of BRP unknown, but neither is the gold-standard treatment.  In its refractory form, physicians often have a difficult path trying to find a solution.

Purpose/Objectives:

We performed a literature review to investigate which mechanism is more likely the culprit of this condition.  We then discussed each treatment found in the literature in order to compile a comprehensive list of possible management strategies to be utilized by providers.  This article identifies previously trialed conservative management and medical management and highlights perhaps an interdisciplinary approach could be taken.

Method: A literature review was conducted via PubMed utilizing keywords brachioradial pruritus, treatment, conservative care, review. 

Results: Previously trialed conservative care included acupuncture, physiotherapy, chiropractic and avoidance of UVR exposure all of which showed some benefit for minimizing symptoms.  Many medications were found to be trialed for this condition with the following results: first-line antipruritic agents were not helpful, antidepressants provided moderate improvement, neuroleptics were very helpful, oral steroids were very helpful, intravenous naloxone treatment showed benefit, and topical interventions had limited success.  Epidural steroid injections were shown to be very helpful and as a final resort in difficult to treat cases, anterior cervical discectomy and fusion showed complete resolution of symptoms in two case studies.

Conclusions: Neuropathic itch can be a frustrating condition for providers and patients and many treatment modalities are often tried before arriving at a helpful treatment for a particular patient. The pathogenesis of BRP continues to be an area of debate. This review found there is significantly more research pointing to cervical spine disease as the root cause. There is an abundance of literature discussing both conservative and invasive treatment strategies with benefits to both. Clinicians who may encounter BRP in practice benefit from up-to-date literature reviews that provide them with a summary of management strategies. Further research is needed to better establish the etiology of this condition so formal treatment guidelines may be established. Perhaps using an interdisciplinary approach or a stepped care approach is indicated in the treatment of BRP.

References: 1. Robbins BA, Schmieder GJ. Brachioradial pruritus. In: StatPearls. Treasure Island, FL:
StatPearls Publishing; 2020 Jan. [Updated 2020 Sep 12]. Available from: https:
//www.ncbi.nlm.nih.gov/books/NBK459321/. 
2. Crevits L. Brachioradial pruritus—a peculiar neuropathic disorder. Clin Neurol Neurosurg.
2006;108:803-805. 
3. Lane J, McKenzie J, Spiegel J. Brachioradial pruritus: a case report and review of the
literature. Cutis. 2008;81:37-40. 
4. Wallengren J. Brachioradial pruritus: a recurrent solar dermopathy. J Am Acad Dermatol.
1998;39:803-806. 
5. Mirzoyev S, Davis M. Brachioradial pruritus: Mayo clinic experience over the past decade.
Br J Dermatol. 2013;169: 1007-1015.
6. Pinto AC, Wachholz PA, Masuda PY, Martelli AC. Clinical, epidemiological and therapeutic
profile of patients with brachioradial pruritus in a reference service in dermatology. An Bras
Dermatol. 2016 Jul-Aug;91(4):549-551. doi: 10.1590/abd1806-4841.201644767. PMID:
27579762; PMCID: PMC4999125.
7. Alai NN, Skinner HB. Concurrent notalgia paresthetica and brachioradial pruritus associated
with cervical degenerative disc disease. Cutis. 2018 Sep; 102190(3): 185186189. 
8. Atis G, Bilir Kaya B. Pregabalin treatment of three cases with brachioradial pruritus.
Dermatol Ther. 2017 Mar; 30(2). 
9. Waisman M. Solar pruritus of the elbows (brachioradial summer pruritus). Arch Derm.
1968;98:481-485.
10. Binder A, Fölster-Holst R, Sahan G, Koroschetz J, Stengel M, Mehdom HM, et al. A case of
neuropathic brachioradial pruritus caused by cervical disc herniation. Nat Clin Pract Neurol
2008; 4: 338-342. 
11. Bernhard J.D., Bordeaux J.S. Medical pearl: the ice-pack sign in brachioradial pruritus. J Am
Acad Dermatol. 2005; 52: 1073.
12. Veien N, Laurberg G. Brachioradial pruritus: a follow-up of 76 patients. Acta Derm
Venereol. 2011;91:183-185.
13. Mataix J, Silvestre JF, ciiment JM, Pastor N, Lucas A. 15 Brachioradial pruritus as a
symptom of cervical radiculopathy. Actas Dermosifiliogr 2008; 99: 719-722.
14. Kavak A, Dosoglu M. Can a spinal cord tumor cause brachioradial pruritus? J Am Acad
Dermatol 2002; 46: 437-440. 
15. Zeidler C, Pereira MP, Ständer S. Brachioradial Pruritus successfully treated with
intravenous naloxone. J Eur Acad Dermatol Venereol. 2022 Aug 20. doi: 10.1111/jdv.18553.
Epub ahead of print. PMID: 35986712. 
16. Shields L B, Iyer V G, Zhang Y, et al. (February 01, 2022) Brachioradial Pruritus: Clinical,
Electromyographic, and Cervical MRI Features in Nine Patients. Cureus 14(2): e21811.
doi:10.7759/cureus.21811.
17. Marziniak M, Phan NQ, Raap U, Siepmann D, Schürmeyer-Horst F, Pogatzki-Zahn E, Niederstadt T,
Ständer S. Brachioradial pruritus as a result of cervical spine pathology: the results of a magnetic
resonance tomography study. J Am Acad Dermatol. 2011 Oct;65(4):756-762. doi:
10.1016/j.jaad.2010.07.036. Epub 2011 Jun 8. PMID: 21641675.
18. Salzmann SN, Okano I, Shue J, Hughes AP. Disabling Pruritus in a Patient With Cervical
Stenosis. J Am Acad Orthop Surg Glob Res Rev. 2020 Mar 9;4(3):e19.00178. doi:
10.5435/JAAOSGlobal-D-19-00178. PMID: 32440634; PMCID: PMC7209791.
19. Golden KJ, Diana RM. A Case of Brachioradial Pruritus Treated with Chiropractic and
Acupuncture. Case Rep Dermatol. 2022 Apr 21;14(1):93-97. doi: 10.1159/000524054.
PMID: 35702723; PMCID: PMC9149350. 
20. Tait CP, Grigg E, Quirk CJ. Brachioradial pruritus and cervical spine manipulation. Australas
J Dermatol. 1998 Aug;39(3):168-170. doi: 10.1111/j.1440-0960.1998.tb01274.x. PMID:
9737043.
21. Freynhagen R, Baron R. The evaluation of neuropathic components in low back pain. Curr
Pain Headache Rep. 2009 Jun;13(3):185-190. doi: 10.1007/s11916-009-0032-y. PMID:
19457278. 
22. Gyer G, Michael J, Inklebarger J, Tedla JS. Spinal manipulation therapy: Is it all about the
brain? A current review of the neurophysiological effects of manipulation. J Integr Med.
2019 Sep;17(5):328-337. doi: 10.1016/j.joim.2019.05.004. Epub 2019 May 9. PMID:
31105036. 
23. Graham N, Gross A, Goldsmith CH, Klaber Moffett J, Haines T, Burnie SJ, Peloso PMJ.
Mechanical traction for neck pain with or without radiculopathy. Cochrane Database of
Systematic Reviews 2008, Issue 3. Art. No.: CD006408. DOI:
10.1002/14651858.CD006408.pub2. Accessed 17 November 2022. 
24. Stellon A. Neurogenic pruritus: an unrecognised problem? A retrospective case series of
treatment by acupuncture. Acupunct Med. 2002 Dec;20(4):186-190. doi:
10.1136/aim.20.4.186. PMID: 12512793. 
25. Bowsher D. Mechanisms of acupuncture. In: Filshie J, White A, editors. Medical
Acupuncture - A Western Scientific Approach. Edinburgh: Churchill Livingstone; 1998. p.
69-82.
26. Lim TK, Ma Y, Berger F, Litscher G. Acupuncture and neural mechanism in the
management of low back pain-an update. Medicines. 2018 Jun 25;5(3):63. 
27. Alai NN, Skinner HB. Concurrent notalgia paresthetica and brachioradial pruritus associated
with cervical degenerative disc disease. Cutis. 2018 Sep;102(3):185;186;189;190. PMID:
30372709. 
28. Raison-Peyron N, Meunier L, Acevedo M, Meynadier J. Notalgia paresthetica: clinical,
physiopathological and therapeutic aspects. A study of 12 cases. J Eur Acad Dermatol
Venereol. 1999 May;12(3):215-221. PMID: 10461640. 
29. Fleischer AB, Meade TJ, Fleischer AB. Notalgia paresthetica: successful treatment with
exercises. Acta Derm Venereol. 2011 May;91(3):356-357. doi: 10.2340/00015555-1039.
PMID: 21279307. 
30. Kouwenhoven TA, van de Kerkhof PCM, Kamsteeg M. Use of oral antidepressants in
patients with chronic pruritus: A systematic review. J Am Acad Dermatol. 2017
Dec;77(6):1068-1073.e7. doi: 10.1016/j.jaad.2017.08.025. Epub 2017 Oct 21. PMID:
29033248.
31. Matsuda KM, Sharma D, Schonfeld AR, Kwatra SG. Gabapentin and pregabalin for the
treatment of chronic pruritus. J Am Acad Dermatol. 2016 Sep;75(3):619-625.e6. doi:
10.1016/j.jaad.2016.02.1237. Epub 2016 May 17. PMID: 27206757.
32. Okuno S, Hashimoto T, Satoh T. Case of neuropathic itch-associated prurigo nodules on the
bilateral upper arms after unilateral herpes zoster in a patient with cervical herniated discs:
successful treatment with mirogabalin. J Dermatol. 2021 Dec;48((12)):e585–6.
33. Papoiu AD, Yosipovitch G. Topical capsaicin. The fire of a 'hot' medicine is reignited.
Expert Opin Pharmacother. 2010 Jun;11(8):1359-1371. doi: 10.1517/14656566.2010.481670.
PMID: 20446852.