David J. Elpern, M.D.
Williamstown, Massachusetts, USA
on November 17, 2001
History: The patient is a 65 year-old woman who presented in September of 2001 with an an intensely pruritic eruption of the right arm for a year. She divides her life between South Florida and Western Massachusetts. An avid athlete, she enjoys tennis and golf. The disorder began in Florida. Her health is good and she takes no medications other than hormone replacement therapy. The pruritus is intense at times and lasts for 1-2 months, then spontaneously subsides. She was given clobetasol ointment by another dermatologist, but it was ineffective. I prescribed EMLA and topical doxepin (Zonalon). She derived some benefit from the EMLA.
Examination: A complete skin exam was unremarkable except for mild lichenification and excoriation of the brachioradial area of the right arm.
Pathology and Laboratory - Not Indicated
Diagnosis: Brachioradial Pruritus (BRP)
Discussion: In or around 1980, while practicing in Hawaii, I started seeing patients with BRP. These individuals had an extremely annoying itch. Many would describe it as a crawling pricking sensation in the affected areas. A colleague had it. He told me he tried potent topical and intralesional steroids without relief. I remember him saying. "Even two scotches in the evening don't help.
BRP was first reported from Florida by Waisman in 1968, and later by Heyl from South Africa (1983). I thought this was a tropical dermopathy, but after moving to the mainland (Massachusetts) in 1993 I continued to see cases, albeit fewer.
Theories as to etiology range from ultraviolet light, to cervical spine disease to nerve entrapment. Treatments are legion: topical steroids, topical antihistamines, local anesthetic creams, capsaicin, chiropractic and recently electrostimulation. I have not found any modality to consistently help these patients,
This woman is being presented for interest and discussion. Does anyone have a therapy that works most of the time for these patients?
MEDLINE lists twenty references under the heading of BRP. To review these, go to http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi and enter the terms brachioradial pruritus.
1. Waisman M., Solar pruritus of the elbows (brachioradial summer pruritus). Arch Dermatol 1968 Nov;98(5):481-5
2. Heyl T., Brachioradial
pruritus. Arch Dermatol 1983 Feb;119(2):115-6
Fourteen patients with brachioradial pruritus are described. In six patients the right arm was involved, in three the left arm, and in five both arms. In four of five patients so examined there was roentgenographic evidence of cervical vertebral osteoarthritis. Although sun exposure may be of etiologic importance, some, or perhaps most, cases may be due to nerve injury, either secondary to lesions of the cervical spine or perhaps resulting from nerve compression by other structures.
J, Sundler F., Cutaneous field stimulation in the treatment of severe itch.Arch
Dermatol 2001 Oct;137(10):1323-5
Department of Dermatology, Lund University Hospital, SE-221 85 Lund, Sweden. Joanna.Wallengren@derm.lu.se
OBJECTIVE: To evaluate the efficacy of cutaneous field stimulation of C fibers for the treatment of itchy skin and its effect on peripheral nerve fibers as shown in skin biopsy specimens. DESIGN: We conducted an open-label uncontrolled study of 19 patients with itching. Each patient applied a flexible plate containing electrodes to the itchy area for 20 minutes at a time once daily for 5 weeks to stimulate nerve fibers with a constant current (0.8 mA). Skin biopsy specimens were collected before treatment and at the end of treatment and were immunostained for calcitonin gene-related peptide and protein gene product 9.5. SETTING: University hospital in Lund, Sweden. PATIENTS: Sixteen patients with nostalgia paresthetica or brachioradial pruritus and 3 with generalized itch. INTERVENTIONS: Cutaneous field stimulation and punch biopsies of the itchy skin. MAIN OUTCOME MEASURES: Visual analog scale for assessment of itching and counting the immunoreactive nerve fibers in 3-mm biopsy specimens. RESULTS: Patients with localized itching experienced a reduction in mean values on the visual analog scale (from 78% before treatment to 42% by the end of the fifth week). The number of protein gene product 9.5- immunoreactive nerve fibers in the epidermis was reduced by 40% by the end of treatment compared with baseline values. CONCLUSIONS: Cutaneous field stimulation is an effective alternative for the treatment of localized itching. The reduction in itching is accompanied by degeneration of the epidermal nerve fibers, as evidenced by the loss of protein gene product 9.5 immunoreactivity.
11/18/01: Have you tried Talidomide? It is effective in Prurigus Nodularis, and we also use in Solar Prurigo.
11/18/01: Thanks. You have made me aware of this condition, which I am certain that I have seen, but did not recognize.
11/18/01: I am convinced nerve entrapment plays a significant role. One patient was nearly disabled by the pruritus, but it disappeared when she stopped working and went back to school. It returned with a vengeance in her new job as a PICU nurse. Lifting was the apparent aggravating factor.
11/18/01: Elavil and Neurontin are useful for neuropathic itches. I have published a case report on BRP and gabapentin in JEADV. You might search on this. Basically, low to moderate doses of Neurontin are useful, but side effects are the limiting factor. Bueller HA, Bernhard JD, Dubroff L are the authors in JEADV.
11/19/01 from Leana C. Quintanilla, M.D.: What happend with this case? Appers like some type of Cromo-blastomicosis. Does the doctor of this case, still thinking about verrucous psoriasis???
11/19/01: Has cervical pathology been ruled out in this case?
D. from Lund University replies:
Thank you for your letter. The disorder is described as chronic intermittent in this tropical climate. In our climate the disorder seems to appear or recur at the end of sunny summers and we do not see it after cold and rainy summers. Patients spending their summers somewhere else in the sun may present with BRP anyway. Exposition to the sun for 2-3 months is common. The disorder normally occurs in August and disappears spontaneously in November in our climate. In one case of chronic BRP, the patient used a sun-bed. Maybe UVL is not the only factor but it seems to be an important one.
As to your patient. You write that her pruritus lasts for 1-2 months. When does it appear? Is it after a couple of months in Florida? If this is the
case maybe she should protect her arms from sun next time she goes to
Florida if she wants to avoid BRP. I still belive that capsaicin is effective while waiting for spontaneous healing.
[While working in Hawaii, I routinely had patients wear long-sleeved shirts, and felt this was of value. This goes along with Dr. Wallengren's suggestions. DJE]
A. Derived from Jalepeno peppers
B. Depletes Substance P from pain fibers
C. Requires frequent and repeat applications for affect
D. Inconsistent use not effective
A. Apply capsaicin cream to affected area 3-5 times daily
IV. Adverse effects
A. Burning sensation on initial application
B. Increased pain for up to first week of application
A. Wash hands thoroughly after capsaicin application