Brachioradial Pruritus


Article Author:
Blake Robbins


Article Editor:
George Schmieder


Editors In Chief:
Ahmad Al Aboud
Jayakar Thomas
Pramod Nigam


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
5/2/2019 3:23:51 PM

Introduction

Brachioradial pruritus (BRP) is a localized neuropathic dysesthesia of the dorsolateral upper extremities. It is commonly seen in middle-aged white females with a seasonal predilection for warmer summer months. Cervical radiculopathy or neuropathy in the upper extremities in conjunction with ultraviolet radiation (UVR) are thought to be causative.[1][2][3] Despite the wide variety of etiologies for pruritus, identification of brachioradial pruritus by dermatologists through the history and physical exam has been straightforward. Further workup, such as imaging, labs, and referral to specialists is rarely required. Therapeutic options are numerous and well-tolerated. Because of the benign transient nature of brachioradial pruritus, the number of reported cases and current studies are relatively low.

Etiology

While not completely elucidated, current theories suggest brachioradial pruritus is a bifactorial process involving cervical nerve irritation and ultraviolet radiation (UVR) of the affected area.[4][5][6]

A large majority of patients diagnosed with brachioradial pruritus will have a positive imaging study with evidence of one or more cervical spine abnormalities. Imaging with x-ray computed tomography (CT) or magnetic resonance imaging (MRI) of patients with suspected or diagnosed brachioradial pruritus revealed cervical spine abnormalities such as degenerative joint disease (DJD), cervical nerve impingement due to disk herniation, osteoarthritis, foraminal stenosis, and others. DJD has been reported as the most common cervical spine abnormality in patients with brachioradial pruritus. Many authors suggest that cervical spine disease between C5 to C8 is causative. The dermatomes of the dorsolateral arms are C5 to C6, and a cervical spine abnormality with evidence of radiculopathy at these levels would be especially suggestive as a cause for brachioradial pruritus. Despite the high frequency of cervical spine abnormalities on imaging,  nearly all brachioradial pruritus patients imaged did not meet the criteria for a cervical radiculopathy. Additionally, only a minority of patients diagnosed with brachioradial pruritus are imaged. This suggests that a cervical radiculopathy not inclusive of radiologic criteria may be responsible for the high frequency of cervical spinal abnormalities in patients with brachioradial pruritus may simply be a confounding finding.

UVR is thought to be a contributing factor of brachioradial pruritus, and many patients report increased symptoms of brachioradial pruritus with sun exposure. The term brachioradial summer pruritus is also used in reference to the increased incidence of brachioradial pruritus during the warm summer months.  A subset of histamine sensitive C-fibers is responsible for the transmission of pruritus. Excessive UVR causes damage and a reduction of these C-fibers. Despite the reduction in cutaneous C-fiber number, increased pruritus is reported with UVR in patients with brachioradial pruritus. This pruritic response to a stimulus that does not normally cause pruritus is known as alloknesis. Many patients report relief of symptoms during the winter months and with sun protection, which supports the role of UVR as a trigger in brachioradial pruritus.

The absence of either radiographically evident cervical nerve irritation or UVR does not preclude the diagnosis of brachioradial pruritus.

Epidemiology

Early isolated case reports suggested that brachioradial pruritus was more common in males. Later larger studies revealed that brachioradial pruritus is seen more commonly in females than males in a ratio 3:1. The mean age at diagnosis is 59, but wide variations in age have been reported. Brachioradial pruritus is more common in lighter skin types, especially those with Fitzpatrick type I and type II skin, than in darker skin types. This factor further supports the role of UVR in the pathogenesis of brachioradial pruritus.

Histopathology

Brachioradial pruritus lacks characteristic histopathological features. Microscopic findings include actinic elastosis and decreased density of epidermal and dermal nerve fibers. Actinic elastosis correlates with a history of extensive UVR exposure. A decrease in the density of nerve fibers is seen with phototherapy treatments and would be consistent with UVR-induced brachioradial pruritus exacerbations during the sunny summer months.

History and Physical

Because pruritus has many etiologies, a thorough history is essential to avoid unnecessary testing and delay in treatment. Brachioradial pruritus has a wide area of presentation but is most commonly reported on the dorsolateral arms. Adjacent areas that may be affected are in the C5 to C6 dermatome and include the upper arms, shoulders, and neck. In addition to pruritus, patients may report pain, stinging, or tingling in the affected area. Brachioradial pruritus is bilateral approximately 75% of the time. [7][8][9]Symptoms are usually present for 2 to 3 years before diagnosis. Patients are typically outdoor enthusiasts such as bikers, hikers, and tanners and may have an extensive history of sunburn. Despite the high frequency of cervical spine abnormalities seen on imaging in patients with brachioradial pruritus, retrospective studies report that very few patients had complaints of neck pain, cervical spine narrowing, or neck trauma.

The physical exam of the affected areas is not impressive and lacks primary cutaneous lesions. Secondary cutaneous lesions such as excoriations, prurigo nodules, or lichenification may be present due to excessive scratching.

Confounding factors include coexistent chronic pruritic conditions, skin diseases, topical or systemic medications and unusual presentations.

Evaluation

The ice-pack sign is considered pathognomonic for brachioradial pruritus. The test is simple and involves placing an ice-pack to the affected area. The patient should report immediate improvement of pruritus that returns shortly after removal of the ice-pack.

Evaluations beyond a thorough history and physical and the ice-pack test are typically unnecessary. Imaging, blood tests, and referrals to appropriate specialists may be required in recalcitrant cases. Imaging modalities such as x-ray, CT, and MRI usually are not required. If imaging of the cervical spine is desired, MRI is the preferred modality. Screening blood work for causes of chronic pruritus can be performed. Referral to neurology for further examinations may be appropriate if a neurological cause is suspected. Neurological examinations include cervical spine imaging and electromyography (EMG).

Treatment / Management

Treatment includes avoidance of UVR, topical medications, systemic medications and in select cases, surgery.

Methods of UVR avoidance include reducing sun exposure, judicious use of sunscreen, and use of long-sleeved UV-protective clothing. This may be difficult for some brachioradial pruritus patients, as many enjoy outdoor activities during the warm summer season. Topical medications include capsaicin, mild steroids, anesthetics, antihistamines, and amitriptyline/ketamine. Earlier reports stated topical capsaicin was the most commonly prescribed initial therapy. A newer study reported the oral tricyclic antidepressant, amitriptyline, was the most commonly prescribed medication for brachioradial pruritus, although gabapentin may be more efficacious. Other oral medications include risperidone, fluoxetine, chlorpromazine, and hydroxyzine. For unknown reasons, systemic antihistamine therapies are ineffective in brachioradial pruritus. Response to treatment was greatest in patients who rated their pruritus as severe and those that continued with longer treatments. [10][11][12]It should be noted that the sample size of most studies are small and differences in the most prescribed and efficacious therapy vary. Surgery was reserved for patients with a correctable cervical spinal abnormality seen on imaging. Very few patients fall into this category.

Enhancing Healthcare Team Outcomes

The diagnosis and management of BRP is very difficult and thus it is managed by a multidisciplinary team that includes a neurologist, hand surgeon, dermatologist, nurse practitioner, primary care provider, internist, and psychiatrist. The condition is more common in middle-aged white females with a seasonal predilection for warmer summer months. Cervical radiculopathy or neuropathy in the upper extremities in conjunction with ultraviolet radiation (UVR) are thought to be causative.

There are hundreds of treatment for the disorder but none works reliably or is better than other treatments. Patients go through exhaustive workup to determine the cause, which is never found in most cases.

The only salvation is the condition is benign but it can seriously affect the quality of life because of the constant itching.[13][3] (Level V)

 


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Brachioradial Pruritus - Questions

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Brachioradial pruritus is generally associated with which geographic or climatic condition?



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Which is not correct about patients with brachioradial pruritus?



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Which of the following primary cutaneous lesions are seen in brachioradial pruritus?



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A 65-year-old white female presents to your clinic in July with a 2-year history of pruritus and tingling on the lateral portion of her arms and shoulders bilaterally. You examine her upper extremities and note that her skin is bronze but without any suspicious lesions. She states that her symptoms get worse while hiking in sunny weather. One day while on the trail she placed her frozen water bottle on her arm and her pruritus improved. She dislikes medications but wants an answer. What do you do?



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A forty-year-old fair skinned male who enjoys competitive sailing presents with chronic localized itching of the arm between the wrist and the elbow. It is so intense he has localized trauma and has developed a secondary cellulitis. He also complains of pain in the neck which he has had for many months. He says the only thing that relieves the itching is ice. Which of the following would be the most appropriate next step?



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Brachioradial Pruritus - References

References

Weinberg BD,Amans M,Deviren S,Berger T,Shah V, Brachioradial pruritus treated with computed tomography-guided cervical nerve root block: A case series. JAAD case reports. 2018 Aug;     [PubMed]
He A,Alhariri JM,Sweren RJ,Kwatra MM,Kwatra SG, Aprepitant for the Treatment of Chronic Refractory Pruritus. BioMed research international. 2017;     [PubMed]
Pereira MP,Lüling H,Dieckhöfer A,Steinke S,Zeidler C,Ständer S, Brachioradial Pruritus and Notalgia Paraesthetica: A Comparative Observational Study of Clinical Presentation and Morphological Pathologies. Acta dermato-venereologica. 2018 Jan 12;     [PubMed]
Alai NN,Skinner HB, Concurrent notalgia paresthetica and brachioradial pruritus associated with cervical degenerative disc disease. Cutis. 2018 Sep;     [PubMed]
Vestita M,Cerbone L,Calista D, Brachioradial pruritus in a 47-year-old woman treated with pregabalin. Giornale italiano di dermatologia e venereologia : organo ufficiale, Societa italiana di dermatologia e sifilografia. 2016 Dec;     [PubMed]
Pinto AC,Wachholz PA,Masuda PY,Martelli AC, Clinical, epidemiological and therapeutic profile of patients with brachioradial pruritus in a reference service in dermatology. Anais brasileiros de dermatologia. 2016 Jul-Aug;     [PubMed]
Atış G,Bilir Kaya B, Pregabalin treatment of three cases with brachioradial pruritus. Dermatologic therapy. 2017 Mar;     [PubMed]
Strowd RE,Strowd LC,Blakeley JO, Cutaneous manifestations in neuro-oncology: clinically relevant tumor and treatment associated dermatologic findings. Seminars in oncology. 2016 Jun;     [PubMed]
Salako KB,Anstey AA,Logan RA, Delayed, transient, postsolar truncal pruritus: a report of two cases. Clinical and experimental dermatology. 2014 Aug;     [PubMed]
Pereira MP,Lüling H,Dieckhöfer A,Steinke S,Zeidler C,Agelopoulos K,Ständer S, Application of an 8% capsaicin patch normalizes epidermal TRPV1 expression but not the decreased intraepidermal nerve fibre density in patients with brachioradial pruritus. Journal of the European Academy of Dermatology and Venereology : JEADV. 2018 Sep;     [PubMed]
Wachholz PA,Masuda PY,Pinto ACVD,Martelli ACC, Impact of drug therapy on brachioradial pruritus. Anais brasileiros de dermatologia. 2017 Mar-Apr;     [PubMed]
Zeidler C,Lüling H,Dieckhöfer A,Osada N,Schedel F,Steinke S,Augustin M,Ständer S, Capsaicin 8% cutaneous patch: a promising treatment for brachioradial pruritus? The British journal of dermatology. 2015 Jun;     [PubMed]
Dhand A,Aminoff MJ, The neurology of itch. Brain : a journal of neurology. 2014 Feb;     [PubMed]

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