Notalgia Paresthetica: Symptoms, Types, Causes and Treatment

Notalgia paresthetica (NP) is a perplexing and often underdiagnosed neurological skin disorder. Most people who experience it are left frustrated by an "unreachable itch" in the middle of their back—one that doesn’t respond to the usual treatments for itchy skin. Beyond itch, NP can bring pain, odd sensations, and sometimes visible changes to the skin. This article offers a detailed, human-centered exploration of NP, covering its symptoms, types, causes, and treatment options, all grounded in the latest evidence.

Symptoms of Notalgia Paresthetica

Notalgia paresthetica doesn’t just cause a simple itch—it’s a complex sensory experience. For most, it starts as an itch just below or between the shoulder blades, but the symptoms can be more diverse and difficult to manage. Understanding these symptoms is the first step to recognizing NP and seeking help.

Symptom	Description	Location	Source(s)
Pruritus	Persistent, sometimes severe itch	Mid-back (T2-T6)	1 3 5 6
Pain	Burning, aching, or sharp sensation	Infrascapular	1 5 6
Paresthesia	Tingling, pins and needles, numbness	Medial scapula	1 3 5
Skin Change	Hyperpigmentation, erythema, thickening	Localized patch	3 6 7

Table 1: Key Symptoms

Chronic Itching and Sensations

The hallmark of NP is a localized, persistent itch (pruritus) in the mid to upper back, usually on one side. This itch often resists scratching and can become so intense that it affects sleep and daily life. Many patients also report:

• Burning, aching, or sharp pain
• Tingling (“pins and needles”)
• Numbness or altered sensation to touch

These symptoms can flare up or recede over time, leading to cycles of remission and relapse 1 3 5 6.

Skin Changes

Over time, relentless scratching or rubbing can cause visible changes to the skin in the affected area. These may include:

• A well-demarcated, hyperpigmented (darker) patch
• Erythema (redness)
• Thickening or rough texture
• Occasionally, a hypopigmented (lighter) area or friction amyloidosis (protein deposits from chronic rubbing) 2 3 6 7

Sensory Disturbances

NP is fundamentally a sensory neuropathy. That means, in addition to itch, patients may notice:

• Abnormal skin sensations (paresthesia)
• Tenderness or increased sensitivity (hyperalgesia)
• Occasionally, decreased sensation in the patch 1 3

Types of Notalgia Paresthetica

Not all cases of notalgia paresthetica are the same. While everyone experiences the same core symptoms, nuances in presentation and underlying risk factors allow clinicians to recognize distinct types or variations.

Type	Defining Feature	Common Age Group	Source(s)
Sporadic	No family history, most common	Middle-aged/elderly	2 3 5
Hereditary	Linked to genetic syndromes (rare)	Young patients	2
Secondary	Associated with spinal/muscle issues	Adults	2 4 8

Table 2: Common Types of Notalgia Paresthetica

Sporadic (Most Common)

Most cases of NP are sporadic. These occur in individuals with no family history or genetic syndrome, typically appearing in middle-aged or older adults. These cases are often associated with degenerative or postural changes in the spine 2 3 5.

Hereditary (Rare)

A much rarer form, hereditary NP, occurs in some young patients, sometimes linked with genetic syndromes such as multiple endocrine neoplasia type 2A. These cases suggest a possible genetic predisposition in a minority of patients 2.

Secondary or Symptomatic

Some people develop NP as a consequence of another underlying condition, most commonly:

• Spinal disorders: Degenerative changes, disc herniation, or arthrosis leading to nerve entrapment
• Muscular dysfunction: Injuries or dysfunction in muscles (e.g., serratus anterior) that compress or irritate sensory nerves 2 4 8

These secondary cases often respond to treatments targeting the underlying musculoskeletal problem.

Causes of Notalgia Paresthetica

The cause of NP remains an area of active investigation. What is now clear is that NP is not a simple skin problem, nor is it caused by allergies or infections. Rather, it involves nerves—specifically those that provide sensation to the skin of the mid-back.

Cause Type	Description	Key Details	Source(s)
Nerve Entrapment	Compression or injury to dorsal spinal nerves	T2-T6 dermatomes	2 3 4 5
Spine Changes	Degenerative, arthrosis, postural issues	Dorsal vertebrae	2 4 5 8
Increased Innervation	Higher density of skin nerve fibers	Affected skin biopsies	1
Muscular Factors	Muscle dysfunction causing nerve irritation	Serratus anterior, others	4 8
Genetic Factors	Hereditary syndromes (rare)	MEN type 2A	2

Table 3: Underlying Causes of Notalgia Paresthetica

Nerve Entrapment and Spinal Changes

The most widely accepted explanation for NP is nerve entrapment or chronic irritation of the posterior rami of spinal nerves (usually T2-T6). These nerves pass through or near muscles like the multifidus, trapezius, and serratus anterior. Structural issues—such as arthrosis, disc problems, or poor posture—can compress these nerves, leading to the symptoms of NP 2 3 4 5 8.

Changes in Skin Nerve Fibers

Biopsies from the affected skin in NP patients show a significant increase in the density of nerve fibers (as demonstrated by PGP 9.5 immunostaining) and a rise in dendritic cells (likely Langerhans cells). This heightened innervation may make the skin more sensitive, contributing to the severe itch and unusual sensations 1.

Muscular and Mechanical Factors

Muscle tightness, trauma, or weakness—especially in the muscles that interact with the scapula—can directly compress nerves or alter posture in a way that increases nerve irritation. Recent studies suggest that injuries to the long thoracic nerve (affecting the serratus anterior muscle) may directly cause NP in some patients 4 8.

Genetic and Rare Causes

Hereditary cases are rare but have been reported, particularly in association with genetic syndromes such as multiple endocrine neoplasia type 2A 2. These cases often present earlier in life.

Other Theories

Other less substantiated theories include lymphatic involvement and electrical impedance changes in the affected area, but these require further research 7.

Treatment of Notalgia Paresthetica

Treating NP can be challenging, as conventional anti-itch therapies often fail. Since it is a sensory neuropathy, the most effective treatments target nerve function or address underlying musculoskeletal problems.

Treatment	Approach/Mechanism	Effectiveness/Notes	Source(s)
Topical Capsaicin	Depletes substance P in nerves	Transient relief, symptoms return	2 4 6 11
Oral Medications	Gabapentin, oxcarbazepine, others	May help neuropathic symptoms	4 6 10
Physical Therapy	Posture, muscle strengthening	Often beneficial, safe	2 4 6 8
Botulinum Toxin A	Reduces nerve activity/itch	Some success in trials	4 6 9
EMS (Muscle Stim.)	Electrical muscle stimulation	Promising for muscle-related NP	8
Others	Tacrolimus, amitriptyline/ketamine	Variable, under study	6

Table 4: Treatment Options for Notalgia Paresthetica

Topical Therapies

• Capsaicin cream: This is the best-studied topical option. It works by depleting substance P, a neuropeptide involved in pain and itch transmission. About 70% of patients report significant (but often temporary) relief; symptoms usually return once treatment stops 2 4 6 11.
• Topical anesthetics, tacrolimus, and compounded creams (amitriptyline/ketamine): These may help some patients, but evidence is limited 6.

Oral/Systemic Medications

• Gabapentin and oxcarbazepine: These are anticonvulsants that target nerve pain and have shown success in small studies and case reports 4 6 10.
• Amitriptyline: An antidepressant with pain-modulating properties, sometimes used for neuropathic itch 6.

Physical and Physiotherapy

Addressing underlying postural or musculoskeletal problems is often key. Effective strategies include:

• Targeted exercises: Strengthening and stretching the scapular and pectoral muscles can relieve nerve compression and improve symptoms long-term 2 4 6.
• Posture correction
• Manual therapy and modalities: Such as ultrasound, massage, or radiation physiotherapy 2 4.

Procedural and Device-Based Treatments

• Botulinum toxin A injections: Small studies and one randomized trial suggest BTX-A can help by reducing nerve signaling, though more research is needed 4 6 9.
• Electrical muscle stimulation (EMS): Particularly effective in cases linked to long thoracic nerve injury and serratus anterior dysfunction 8.
• Transcutaneous electrical nerve stimulation (TENS): Has been reported to reduce symptoms in some patients 4.

Treatment Algorithm

Experts recommend a stepwise approach:

1. Start with topical agents and physical therapy
2. If inadequate, try oral medications
3. Consider procedural interventions for refractory cases
4. Combine therapies for best results 6

Other Considerations

• NP is benign but chronic; reassurance and education are important
• Avoid excessive scratching to minimize skin damage
• Symptoms often wax and wane; some cases resolve spontaneously

Conclusion

Notalgia paresthetica is a surprisingly common but often unrecognized sensory neuropathy of the back. Its hallmark is a stubborn, localized itch, but symptoms and the underlying mechanisms are far more complex. Here are the main points:

• Symptoms: Persistent, localized itch, pain, and abnormal sensations, often with visible skin changes
• Types: Most cases are sporadic, but hereditary and secondary forms exist
• Causes: Largely due to nerve compression or irritation, with contributions from spinal, muscular, and—in rare cases—genetic factors
• Treatment: Topical and systemic therapies targeting nerve function, along with physical therapy, offer the best hope for relief

Understanding NP’s multifactorial nature allows for more effective, individualized treatment, helping patients finally reach that “unreachable itch.”