Treatment of notalgia paraesthetica with an 8% capsaicin patch

Correspondence Treatment of notalgia paraesthetica with an 8% capsaicin patch DOI: 10.1111/j.1365-2133.2011.10501.x MADAM, Two patients with severe pruritus on the upper back were referred to our outpatient pruritus clinic. The first patient, a 73-year-old woman, was diagnosed with an atypical form of notalgia paraesthetica (NP) presenting with prurigo nodularis-like skin lesions in two symmetrical paravertebral hyperpigmented maculae with intense itching (Fig. 1a). An X-ray revealed a herniated vertebral disc in the cervical spine, matching the affected dermatomes. The second patient was a 61-year-old woman with NP complaining of intense itch located in the right mid-scapular region. She presented with a hyperpigmented, mildly erythematous macula in the area of the pruritus. Radiological examination revealed kyphosis and spondylitis of the thoracic spine. Both patients had multiple previous topical and systemic treatments. (a) (b) Fig 1. Short-term effect of an 8% capsaicin patch in a patient with bilateral severe localized itch and hyperpigmented maculae and prurigo-like skin lesions on the upper back (a). (b) Itch severity was recorded daily by the patient on a scale ranging from 0 (no itch) to 10 (maximal itch) before and after a 20 min application of Qutenza at day 0 (Q). BJD British Journal of Dermatology We decided to treat both patients for 60 min with Qutenza (NeurogesX, Inc., San Mateo, CA, U.S.A.), an 8% capsaicin patch. The first patient tolerated the patch for only 20 min because it became too painful. The second patient tolerated the patch well, with a mild to moderate burning sensation throughout the application time and for a further 30 min. Capsaicin treatment is known to lead to stinging and burning, therefore the area of contact with the 8% capsaicin patch has to be pretreated with EMLA (AstraZeneca, London, U.K.). The most likely reason for the painful sensation in the first patient is that there were some erosive lesions in the pruritic areas. Although we anticipated that this could be a limiting factor (and informed the patient accordingly), the patient was willing to proceed. After removal of the patch, pruritus was considerably decreased in both patients (Figs 1b and 2a). While pruritus returned within a few days to almost maximum itch intensity in the first patient, the second patient stayed completely free of any itching sensation (Fig. 2a) and 8 weeks after the treatment, the macula on the back was visibly less pigmented and less erythematous (Fig. 2b, c). Currently, the patient is 12 weeks post-treatment and is still free of any symptom. Chronic pruritus is a major therapeutic problem and can severely impact quality of life. Depending on the underlying cause, itch can have many different qualities, different time courses and can be generalized or localized. A typical form of localized chronic pruritus is neuropathic pruritus as seen for example in NP or brachioradial pruritus. NP results from nerve entrapment of the posterior rami, usually of spinal nerves arising at T2–T6.1,2 Patients usually complain of severe unilateral pruritus on the mid or upper back, often, but not always, associated with a hyperpigmented patch in the affected area.3 Often, degenerative changes and other vertebral pathologies such as a herniated nucleus pulposus can be found.1 Currently, there is no evidence-based therapeutic approach for the treatment of NP or other forms of localized chronic pruritus. Treatment strategies include neurosurgical and orthopaedic approaches,4,5 systemic therapy with gabapentin6 and topical therapy with local anaesthetics, corticosteroids or capsaicin.3 Although topical capsaicin has been shown to improve itching in some patients with NP, there are several limitations to this treatment: (i) it needs to be repeated 5–6 times daily; (ii) it may stain clothes and bedding; and (iii) great care has to be taken not to rub fingers in the face, nose or eyes after application of the cream. Here, we report two cases of localized pruritus treated with a single application of an 8% capsaicin patch. A single applica-  2011 The Authors BJD  2011 British Association of Dermatologists 2011 165, pp1359–1366 1359 1360 Correspondence (a) (b) (c) Fig 2. Effective and long-lasting suppression of severe localized pruritus in a patient with notalgia paraesthetica by a single application of an 8% capsaicin patch. (a) Itch severity was recorded daily by the patient on a scale ranging from 0 (no itch) to 10 (maximal itch) before and after a 60 min application of an 8% capsaicin patch at day 0 (Q). Pictures were taken before (b) and 7 weeks after application of the patch (c). tion of this capsaicin patch was found to reduce post-herpetic pain by about 30%7 and it has recently been approved for the treatment of peripheral neuropathic pain. As it is known that itch, in contrast to pain, originates exclusively from the upper layers of the skin,8 we speculated that a high concentration capsaicin patch could also be effective in neuropathic itch, as the active ingredient is likely to reach a high percentage of itch fibres in the affected area. Furthermore, recent reviews by Yosipovitch and colleagues also considered the 8% capsaicin patch to be a promising antipruritic agent, especially in neuropathic itch.9,10 In summary, the 8% capsaicin patch resulted in a dramatic and long-lasting reduction of pruritus in one patient and provided temporary relief of itch in the other. We speculate that the early reoccurrence of itching in the first patient was because of the short time of contact with the capsaicin patch. To our knowledge, this is the first report of the treatment of localized pruritus with an 8% capsaicin patch. The major advantage of the 8% patch over the often used 0Æ025% capsaicin ointment is the possibility of a longlasting effect after a single application. Further investigations and controlled clinical trials have to be performed to explain the exact mechanisms of 8% capsaicin on itch fibres and to get a better idea about the efficacy of the patch in NP and possibly other diseases with localized chronic pruritus. Acknowledgments We thank Nikki Rooks and Hesna Gözlükaya for excellent technical assistance. Allergie-Centrum-Charité, Department of Dermatology and Allergy, Charité – Universitätsmedizin Berlin, Charitéplatz 1, D-10117 Berlin, Germany E-mail: martin.metz@charite.de M. METZ K. KRAUSE M. MAURER M. MAGERL References 1 Savk O, Savk E. Investigation of spinal pathology in notalgia paresthetica. J Am Acad Dermatol 2005; 52:1085–7. 2 Wang CK, Gowda A, Barad M et al. Serratus muscle stimulation effectively treats notalgia paresthetica caused by long thoracic nerve dysfunction: a case series. J Brachial Plex Peripher Nerve Inj 2009; 4:17. 3 Yosipovitch G, Samuel LS. Neuropathic and psychogenic itch. Dermatol Ther 2008; 21:32–41. 4 Fleischer AB, Meade TJ. Notalgia paresthetica: successful treatment with exercises. Acta Derm Venereol 2011; 91:356–7. 5 Williams EH, Rosson GD, Elsamanoudi I et al. Surgical decompression for notalgia paresthetica: a case report. Microsurgery 2010; 30:70–2. 6 Loosemore MP, Bordeaux JS, Bernhard JD. Gabapentin treatment for notalgia paresthetica, a common isolated peripheral sensory neuropathy. J Eur Acad Dermatol Venereol 2007; 21:1440–1.  2011 The Authors BJD  2011 British Association of Dermatologists 2011 165, pp1359–1366 Correspondence 1361 7 Wallace M, Pappagallo M. Qutenza: a capsaicin 8% patch for the management of postherpetic neuralgia. Expert Rev Neurother 2011; 11:15–27. 8 Handwerker HO. Microneurography of pruritus. Neurosci Lett 2010; 470:193–6. 9 Papoiu AD, Yosipovitch G. Topical capsaicin. The fire of a ‘hot’ medicine is reignited. Expert Opin Pharmacother 2010; 11:1359–71. 10 Tey HL, Yosipovitch G. Targeted treatment of pruritus: a look into the future. Br J Dermatol 2011; 165:5–17. Funding sources: none. Conflicts of interest: none declared. Patient-reported outcomes in psoriasis research and practice DOI: 10.1111/j.1365-2133.2011.10469.x MADAM, Several studies have shown that psoriasis vulgaris and psoriatic arthritis affect patients not only physically, but also socially, emotionally and psychologically, as much as cancer or heart disease.1–4 Additionally, traditional clinical outcomes measures, such as Psoriasis Area and Severity Index, show only weak associations with patient-reported outcomes (PRO).5 Considering that and the fact that psoriasis is still not curable, the most important treatment aims are to control the disease progress and to reduce its harmful effects on the patient’s quality of life (QoL), including parameters such as well being, anxiety, depression and work limitations, among others. Consequently, various QoL measures have been proposed and used to evaluate the impact of psoriasis and its treatment on patients’ health-related QoL (HRQoL).6,7 The aim of this correspondence is to provide information about the tools most used to evaluate the impact of treatments on patients’ QoL or other PRO between 2000 and 2010. The data were obtained from the PubMed (National Library of Medicine) database by systematic review using the keywords ‘psoriasis’ and ‘quality of life’ and a sensitive, broad clinical query using research methodology filters to therapy category (http://www.ncbi.nlm.nih.gov/entrez/query/static/ clinicaltable.html). Abstracts retrieved were analysed to determine which clinical outcomes and ⁄or PRO measures had been used in the studies. We analysed a total of 499 publications, of which 238 were considered to report PRO in psoriasis. The countries which contributed the most articles were the U.S.A. (33Æ1%), Germany (9Æ6%) and the U.K. (8Æ4%). The greatest proportion of papers was published in the British Journal of Dermatology (11Æ2%), followed by the Journal of the American Academy of Dermatology (6Æ2%) and the Journal of the European Academy of Dermatology and Venereology (4Æ4%).  2011 The Authors BJD  2011 British Association of Dermatologists 2011 165, pp1359–1366 Table 1 Most commonly used patient-reported outcomes measures in psoriasis articles published between 2000 and 2010 Questionnaires Dermatology Life Quality Index (DLQI) Short-Form-36 Health Survey (SF-36) [all versions] Health Assessment Questionnaire (HAQ) [all versions] Psoriasis Disability Index (PDI) [all versions] EuroQoL (EQ-5D) Impact of Psoriasis on Quality of Life (IPSO) Nail Psoriasis Severity Index (NAPSI) SKINDEX-29 (SD-29) Self-Administered PASI (SAPASI) Beck Depression Inventory (BDI) Psoriasis Life Stress Inventory (PLSI) Others Total Psoriasis specific Dermatology specific Generic % n 97 35 40Æ8 14Æ7 20 8Æ4 20 18 14 9 6 5 3 3 8 238 55 103 80 8Æ4 7Æ6 5Æ9 3Æ8 2Æ5 2Æ1 1Æ3 1Æ3 3Æ3 100 23Æ1 43Æ2 33Æ6 The most frequently used tools are shown in Table 1. The Dermatology Life Quality Index was the most used measure (40Æ8%). There were seven different generic QoL instruments used most frequently: Short-Form-36 Health Survey (SF-36), Health Assessment Questionnaire, EuroQoL, Beck Depression Inventory, Hospital Anxiety and Depression Scale, Brief Symptom Inventory and Nottingham Health Profile. The SF36 was the generic HRQoL measure used the most (14Æ7%). Regarding psoriasis-specific instruments used to evaluate the impact of specific aspects of the disease on patients’ HRQoL, nine different ones were most used in the last 10 years, the most frequently applied being the Psoriasis Disability Index (8Æ4%). Pavlovsky et al.8 showed that between 1993 and 2007 there was a significant increase in the number of all types of psoriasis publications. The authors suggest that this increase is supported by basic research discoveries, where the better understanding of psoriasis immunopathology has led to an increase in clinical studies, and by the discovery of biological treatments. Similarly, our results show that concern about PRO in psoriasis care has increased continuously in the last 10 years, being more evident from 2003, coinciding with the emergence of biological agents for psoriasis treatment (Fig. 1).9 In summary, the use of instruments for measuring PRO and QoL has grown over the years in studies involving patients with psoriasis. This demonstrates the growing importance of issues that go beyond the strictly clinical aspects and severity of the disease. The high variability in the use of humanistic outcome assessment tools to evaluate the impact of psoriasis and its treatments is a consequence of the lack of standardized