“It feels like a mosquito bite... but deeper. The more you scratch, the worse it gets."
"It’s not sharp or excruciating—it’s just irritating, and you start to dig at it.
"It’s a burning, focused itch—like a pinprick that won't go away." 

These are just a few of the ways patients describe the persistent itch of Notalgia Paresthetica (NP) - a condition that may seem minor at first glance but can significantly disrupt daily comfort and quality of life. Unlike typical skin itches, NP sensations are intense, recurrent, and often confined to a specific area, typically just below the shoulder blade.¹ This article explores the common symptoms of NP and how they affect people living with this condition. 

Overview of NP

The Greek words “notalgia” and “paresthetica” mean “back pain” and “a prickling or tingling sensation”.² NP is a chronic disease caused by damage or malfunction of sensory nerves that transmit sensations, such as touch, pain, temperature, or vibration. This leads to itching on the upper or middle back, usually near the shoulder blade, in an area known as the interscapular or paravertebral region. 

NP usually occurs without an underlying skin disease. Experts consider it a type of neuropathic itch, which accounts for approximately 8% - 19% of chronic itch cases; however, the prevalence may be underreported due to diagnostic challenges.^3,4,5,6 

Although not widely recognised, studies indicate that NP predominantly affects adults, particularly individuals assigned female at birth (AFAB) over 40 years of age, with a ratio of roughly 2:3. Rare hereditary forms may appear in children as young as six, often linked to multiple endocrine neoplasia type 2A disorder (MEN 2A).^2,4,5,7 

NP is often underdiagnosed, underscoring the importance of recognising its distinctive symptoms and ensuring accurate diagnosis.³

What causes NP?

The exact cause of NP remains unclear. However, most evidence points to injury, irritation or compression of the posterior branches of the second to sixth thoracic nerves (T2-T6 dermatomes) as the primary mechanism.^4,7,8,9

A study suggests that these nerves are particularly susceptible because they pass perpendicularly through the multifidus muscle, making them prone to entrapment.⁸  Others link the condition to degenerative spine changes, including degenerative disc disease or nucleus pulposus herniation.⁴

Additional factors that may lead NP include:^2,4,8,9

• Tight or stiff connective tissue in the neck that irritates nearby nerves
• Tension in neck and shoulder muscles is causing nerve compression
• Long thoracic nerve injury leading to weakness of the serratus anterior muscle and subsequent nerve irritation
• Pinched cervical nerves (C5–C7) affecting shoulder blade function
• Weakness of scapular stabiliser muscles (rhomboids or trapezius)
• Nerve damage due to exposure to toxic chemicals

A different theory proposes that NP may result from a buildup or congestion of fluid in the thoracic duct, a major lymphatic vessel responsible for immune and waste drainage. When this duct becomes congested, inflammatory substances (called mediators) may accumulate in the surrounding tissues. These substances may activate C & Aδ fibres, which are specialised nerve fibres that convey an itch sensation, producing persistent itch. This theory may explain NP’s predominant left-sided occurrence (≈79%) since the thoracic duct typically runs along the left side, though in 5–20% of people it runs on the right, correlating with right-sided symptoms.^10,11,12

Another study identified an increased number of sensory nerve fibres in NP-affected skin compared with healthy skin, using PGP 9.5 staining.  Despite the increase in nerve fibres, there was no significant difference in neuropeptides (like substance P and CGRP), which are usually linked to pain and inflammation. Elevated numbers of S-100-positive Langerhans cells were also found, suggesting these immune cells might worsen symptoms, though more research is needed.^8,13,14

Common symptoms of NP

Symptoms are usually unilateral, though bilateral cases occur. Across studies, NP presents with:^1,4,5,8 

• Persistent itch (pruritus) 
• Numbness
• Burning or cold sensation
• Tingling ("pins and needles")
• Prickling sensations 
• Heightened sensitivity (hyperesthesia)
• Temperature changes in the affected area
• Stinging
• Pain 
• Thin skin
• Throbbing 
• The sensation of something being “stuck” beneath the skin

Secondary symptoms

Chronic scratching and rubbing can lead to visible changes:^1,4,5,8 

• Dark patches (hyperpigmentation) on the affected skin on one or both sides from chronic scratching and rubbing
• A  net-like pattern similar to macular amyloidosis
• Varying degrees of thickened, rough areas (lichenification)
• Scaling, scratch marks, swelling, bleeding, or redness

A dermatology survey found that 94.2% of dermatologists reported persistent itching as the most consistent symptom. Hyperpigmentation was second (56.6%), followed by increased sensitivity (38.9%).¹

Symptoms often persist for years, with fluctuating flare-ups and remissions. Some cases resolve spontaneously, while others relapse without an identifiable trigger. ^4,8

Exacerbating factors of NP

A qualitative study revealed that patients often identified weather and temperature as key triggers: hot weather, sweating, dry air, hot showers, and sun exposure frequently worsened itching. Patients also noted that itch intensity and location could vary daily or even throughout the same day.¹ 

Impact on quality of life

Although NP is not life-threatening, it can significantly affect daily life.

According to a survey of dermatologists:¹

• Most patients (73%)  rated itching as moderate to severe (5 or higher on a 10-point scale)
• 43% found the constant urge to scratch most distressing
• 40% had difficulty falling asleep, and 37% struggled to stay asleep
• Around one-third reported challenges performing daily activities, often relying on back scratchers or frequent lotion use
• 70% felt regularly irritated or frustrated, 59% experienced emotional reactivity, 13% reported anxiety, and smaller proportions noted impacts on concentration, social life, relationships, or finances

These findings show that NP is more than just a skin condition - it significantly disrupts sleep, daily functioning, and emotional well-being.¹ 

How NP differs from skin conditions with similar symptoms 

While NP shares features with other pruritic skin conditions, it differs due to its neurological origin and confinement to thoracic dermatomes. Accurate diagnosis is crucial to distinguish NP from:

• Pigmented contact dermatitis: caused by allergic reactions to substances like fragrances or cosmetics; typically affects the face and is identifiable via patch testing. NP is not allergen-related.⁴
• Parapsoriasis: presents with multiple lesions and requires a biopsy showing disrupted cell growth; NP usually affects one localised area.⁴
  
• Lichen simplex chronicus: results from psychological stress and habitual scratching; affects accessible sites (neck, arms, genitals). NP involves a neuropathic rather than psychogenic itch.⁴
• Macular amyloidosis: causes itching between the shoulder blades, but features amyloid protein deposition seen with Congo red staining—absent in NP.⁴
• Tinea versicolor: a fungal infection by Malassezia species; distinguishable via potassium hydroxide testing or Wood’s lamp examination. NP typically shows non-specific post-inflammatory changes on biopsy.⁴

When to see a dermatologist

You should consider seeing a dermatologist if:

• You have had persistent itching localised to your upper back, especially near the shoulder blade, for several weeks or longer
• You are noticing skin changes such as dark patches, thickened skin, or scratch marks in the affected area
• The itching is interfering with your sleep, daily activities, or emotional well-being
• You have been diagnosed with another skin condition, but treatments have not worked, and the itch continues

A dermatologist can help rule out other causes of chronic itching, confirm whether it is NP, and suggest treatments that address the nerve-related cause rather than only the skin manifestations.

Summary

NP is a nerve-related condition that causes a persistent, often intense itching sensation, typically on one side of the upper back, just below or along the shoulder blade. Unlike regular skin itches, the itch in NP is deep, recurrent, and may feel like burning, tingling, prickling, or numbness. Many people describe it as a “pinprick that won’t go away” or a “deep mosquito bite” that worsens with scratching.

Over time, repeated scratching and rubbing can lead to visible skin changes such as dark patches (hyperpigmentation), thickened or leathery skin (lichenification), scaling, and sometimes even bleeding or pain. Although the itching is usually localised, some individuals experience it on both sides. Symptoms can persist for years, with periods of flare-ups and relief, and may be worsened by factors like heat, dry weather, sweating, or stress.

While not life-threatening, NP can significantly affect daily comfort, sleep, and emotional well-being. Identifying these symptoms early is essential for accurate diagnosis and effective treatment.