Notalgia Paresthetica (NP) is a nerve condition which causes severe itching, intense stinging, and burning sensations mainly around the middle area of the shoulder blades on either side of the back.¹ The affected area usually leaves a discoloured patch due to the excessive itching or scratching of the back to relieve irritation. The purpose of this article is to compare NP with other similar neurological conditions and highlight their key distinguishing features.

What is notalgia paresthetica? 

‘Notalgia’ is defined as pain in the back, and ‘Paresthetica’ refers to the sensation of burning or numbness.¹ The main features of the condition are the distinctive chronic itch, burning and numbness in the upper back. 

The exact cause of the condition is not entirely known; however, it has been thought to be due to partial pressure or damage to the spinal nerves which supply the upper back. The damage is thought to be caused by progressive deterioration and change to the upper part of the spine. The risk of developing NP is increased when you have a back injury, slipped disc, osteoarthritis, kyphosis (curvature of the spine that causes the top of the back to appear more rounded than normal)² or compression of the muscle fibres.³ Unfortunately, due to a lack of treatment for the condition, this can massively impact quality of life.

Clinical features and diagnosis of notalgia paresthetica

Distinctive features of the condition are an intense itch (pruritus) between or below the shoulder blades, which typically affects mainly one side, and this can either be occasional or continuous and last up to weeks.

The itch is often accompanied by:

• Pain
• Burning sensation
• Cold sensation
• Tingling
• Numbness
• Abnormal skin sensation

Diagnosing the condition is mainly done by the symptoms described and the specific areas affected. Physical examination and detailed medical history should also be obtained, while in certain cases, imaging methods may be considered, such as X-ray or skin biopsy - this is usually reported as normal unless there is an overlying skin condition. Results may display bony changes or slipped discs in the area that corresponds to the nerve supply to the affected skin. In many cases, no abnormality is seen.¹

In many patients, a rash is absent; however, when itching and scratching the affected area, it can lead to:

• Scarring or scratch marks
• Hyper / Hypopigmentation (dark or light patches on the skin)

Your GP may then consider a differential diagnosis such as Lichen simplex (a type of eczema² or fungal infection, which may present similarly.

Comparison with other neuropathic conditions

Meralgia paraesthetica - MP 

A condition which causes an abnormal sensation in the outer area of the thigh. Similarly to NP, it is characterised by pain, burning or itching. The condition is more common in women than in men⁶ and most common in the 30s or 40s, but can occur in all ages (rare in children) and is more typical in pregnant patients or those with obesity.⁶

The condition is caused by injury or a trapped part of the lateral femoral cutaneous nerve (LFCN) (the nerve that supplies sensation to the outer thigh).⁵ The nerve may also be compressed for a number of reasons, such as pressure on the LFCN from tight seat belts, belts, or restrictive clothing or increased intra-abdominal pressure from obesity, pregnancy or tumours.⁵ Certain sports may also contribute to the injury of the LCFN, such as gymnastics, baseball, football and strenuous exercise

The most common symptoms of the condition are:

• Burning and stinging pain on the outer thigh(s) - typically unilaterally 
• Pins and needles in the outer thigh
• Pain aggravated by walking, prolonged standing or standing from a seated position
• Symptoms can be relieved by lying down with the knee bent or when the hip is flexed

Trigeminal neuralgia - TN

A long-standing pain condition which causes quick attacks of facial pain. Often affects the fifth facial nerve, known as the trigeminal nerve, which supplies feeling to the face and head.⁷ The pain is usually unpredictable and can last anywhere between a few seconds and 2 minutes.⁸ In most cases, the condition mainly affects one part of the face and may occur hundreds of times a day.⁸

The 3 main types of trigeminal neuralgia:

• Classical trigeminal neuralgia – described above. This is the most common form
• Secondary trigeminal neuralgia, which is caused by another medical condition or disorder that applies pressure to the nerve, for example:
  • A cyst
  • A tumour 
  • Facial injury
  • Damage to the nerve by surgery, i.e dental procedure
• Idiopathic trigeminal neuralgia – this is when the cause of the condition is unknown, and this is the least common

The main clinical features of the condition include:

• Sudden shock, like facial pain, on one side of the face (unilateral)
• Jaw, Cheek or tooth pain
• Persistent throbbing, aching or burning sensation between episodes
• The attacks are short-lived, lasting a few seconds to 2 minutes and stopping suddenly
• Symptoms are usually aggravated by cold air, light touch to the face, eating/chewing, talking, head movements and smiling. Pain can also be spontaneous without any triggers at all

Post-herpetic neuralgia - PHN 

PN is a long-lasting nerve pain that occurs after the shingles rash has cleared. Shingles is caused by the chickenpox virus (varicella-zoster). Once infected by the virus, it remains in the nerves in your body. If you become unwell or are on immunosuppressants, this can cause the virus to activate again and cause a painful rash. which often improves gradually as the rash disappears, but the pain can persist or stay longer than usual, and this is PHN.⁹

The symptoms of PHN include:

• Pain, burning and aching around the area of skin affected by the shingles rash
• Increased skin sensitivity to touch
• Itchy skin

Symptoms can vary from mild to  severe, which can affect sleep and, in some cases, lead to depression

What is the treatment of notalgia paraesthetica?

Treating NP is often difficult as the cause of the condition still remains unclear, and there is no well-defined treatment to manage the condition. Additionally, treatment is not always successful and can be resistant to many treatments. 

Typical management is usually to aid the symptoms, mainly the itching, and this is done using antihistamines and topical corticosteroids. Alternative treatments include:

• Cooling lotions or creams 
• Local anaesthetic creams 
• Medications - for nerve pain and to aid with sleep disturbances, i.e Amitriptyline 
• Physiotherapy with exercises and stretches for the upper back has been said to be effective
• Botulinum toxin (Botox) 
• Acupuncture 

Surgical treatment, although rarely done, involves taking the pressure off the nerve (surgical decompression) and releasing any pressure or trapped nerve. This is typically done in severe cases

Summary table

Frequently asked questions (FAQs)

Is notalgia paresthetica dangerous?

No, it is not life-threatening; however, the persistent itching and discomfort can have an impact on the quality of life.

Is there a cure for NP?

At present, there is no conclusive cure, and the management is mainly to provide symptomatic relief.

Can I develop all these neurological conditions at the same time?

It is uncommon but not impossible. A detailed history and investigation may differentiate overlap in symptoms. 

Can NP go away without any treatment?

In some cases, symptoms may resolve over time, but in most people, they require ongoing treatment.