AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• INTRODUCTION
• CLINICAL
• DIFFERENTIALS
• WORKUP
• TREATMENT
• MEDICATION
• FOLLOW-UP
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• INTRODUCTION
• CLINICAL
• DIFFERENTIALS
• WORKUP
• TREATMENT
• MEDICATION
• FOLLOW-UP
• Multimedia
• References

Background

Brachioradial pruritus is a neurogenic itch syndrome of the upper extremities. It is typically localized to the skin on the dorsolateral forearm overlying the proximal head of the brachioradialis muscle, but involvement of the upper arms and shoulders is also common.^{1, 2} It may be unilateral or bilateral. Scratching reportedly only makes the discomfort worse, and most patients discover that application of cold packs is often the only therapy that provides symptomatic relief.³ Brachioradial pruritus was first described in Florida in 1968 by Waisman⁴ and has since been reported from subtropical areas such as South Africa¹ and Hawaii.⁵ It is seen less frequently, but still with regularity, in temperate climes.

Pathophysiology

The condition appears to represent a primary neuropathy. Abnormalities in cutaneous innervation have been documented among patients with brachioradial pruritus. Massey and Massey⁶ reported altered sensation to temperature and pinprick in the distribution of the posterior cutaneous nerve of the forearm, which supplies the skin over the brachioradialis muscle that is typically pruritic. Among patients with brachioradial pruritus, heat hyperalgesia in the C5-C6 distribution⁷ and pinprick hyperesthesia in the C5-C8 distribution⁸ have been reported. Wallengren and Sundler⁹ used neuronally directed antibodies to show that patients with brachioradial pruritus have reduced numbers of dermal and epidermal nerve fibers, and, moreover, that this reduction in cutaneous innervation only occurs during symptomatic flares.

The pruritus experienced by patients with brachioradial pruritus is believed to be a variant of pain.⁶ However, the anatomic location of the neural injury or irritation producing this pain is controversial. Two prevailing hypotheses are proposed. The first postulates that brachioradial pruritus is caused by injury to peripheral cutaneous nerves from sunlight exposure. The second suggests that nerves are damaged at the level of the cervical spine. Both mechanisms appear to be active in many patients.

Evidence supporting the solar hypothesis includes the following:

• Many patients with brachioradial pruritus have a history of chronic sun exposure.^{2, 10, 11} Kestenbaum and Kalivas¹² postulated that histamine release from mast cells in response to chronic sun exposure might play a pathophysiologic role; they reported a patient with brachioradial pruritus and an elevated serum histamine level.
• In some cases, sun exposure has been reported to exacerbate symptoms and photoprotection has been reported to provide amelioration.^{4, 13, 14}
• Patients typically only describe symptoms on the sun-exposed dorsal surface of the arms and shoulders.^{2, 5}
• Left-sided symptoms are more common than right-sided symptoms in the United States, which may be the result of cumulative sun exposure to the arm from driving.⁵ In South Africa, where drivers sit on the right-hand side of cars, the distribution is more often on the right arm.¹
• Symptoms among patients living in temperate climates often remit in the late fall and recur in the summer.^{2, 4} Patients living in tropical climates, where it is sunny year round, tend to report symptoms that are more stable.⁵
• Biopsy of affected skin typically shows atrophy and signs of sun damage.^{2, 7}
• The reduction in epidermal and dermal nerve fibers seen in brachioradial pruritus patients is also seen after serial phototherapy.⁷

Challenges to the solar hypothesis include the following:

• If the dorsal surfaces of the arms are affected because they are exposed to the sun, then why is the sun-exposed face unaffected? 
• Why does no lower extremity equivalent of brachioradial pruritus occur in people who wear shorts? 
• If brachioradial pruritus is a manifestation of sun-induced nerve damage, why are children, who are typically very sensitive to the sun, never affected?

Evidence supporting the cervicogenic hypothesis includes the following:

• Several authors have reported a higher prevalence of cervical spine disease (eg, arthritis, spondylolytic changes) among patients with brachioradial pruritus.^{1, 7, 15, 16}
• Treatment of cervical spine arthritis has been reported to provide relief in patients with brachioradial pruritus.^{1, 17}
• Cervical spine tumors,¹⁸ cervical ribs, and hypertrophic cervical transverse processes¹⁹ have all been reported in case series to cause upper extremity pruritus.
• Electrophysiological studies on patients with brachioradial pruritus have shown bilateral delay of F responses of median and ulnar nerves.²⁰

Critics of the cervicogenic hypothesis note the following:

• Cervical spinal disease is generally a permanent disorder and, as such, should produce a continuous neuropathic itch, rather than relapsing and remitting symptoms.
• Cervical nerve blocks have been reported to be unhelpful. This may suggest that the location of the lesion is either more central (dorsal horn) or more peripheral (sensory nerve endings in the arm). 
• Degenerative cervical spinal changes are found in 70% of asymptomatic women and 95% of asymptomatic men older than 65 years²¹; thus, without age-matched controls, implicating cervical spinal disease as the cause of brachioradial pruritus is erroneous.²²
• Conventional electrophysiological testing may not be appropriate in investigating the pathophysiology of brachioradial pruritus because it measures conduction of myelinated fibers, while the afferent nerves that transmit itch are actually unmyelinated.⁷

Frequency

United States

The prevalence of brachioradial pruritus is unknown. Brachioradial pruritus was initially described as a disease of the tropics; however, in more recent years, it has also been documented in temperate climates.

Brachioradial pruritus is typically sporadic, although an autosomal dominant inheritance pattern has been reported in one family, with 11 members across 2 generations experiencing symptoms.¹⁰

Brachioradial pruritus has been reported among patients in California,⁸ Massachusetts,^{3, 16} North Carolina,⁶ Kansas,¹² Florida,⁴ and Hawaii.⁵

International

Brachioradial pruritus has been described among patients in South Africa,¹ Ireland,¹⁵ Sweden,¹⁰ France,²³ Denmark,^{2, 11} Belgium,⁷ Turkey,^{18, 22} Israel,²⁰ and Australia.¹⁷

Mortality/Morbidity

The intense tingling, burning, and itching associated with the disease often keeps patients awake at night.⁴ Frustration from a lack of relief of symptoms with conventional antipruritis agents is common.

Race

Brachioradial pruritus has been reported among patients with all skin types, but whites (Fitzpatrick skin types I-III) appear to be affected more often than darker-skinned individuals.⁵

Sex

Brachioradial pruritus was first reported among middle-aged male outdoor workers⁴; however, more recently, cases have been widely documented among both men and women.^{2, 10, 16}

Age

The onset of symptoms in persons with brachioradial pruritus typically occurs in the fourth to sixth decades of life. The youngest patient reported to have symptoms is an 18-year-old woman whose mother, sister, and 2 aunts also had brachioradial pruritus.¹⁰

CLINICAL

Section 3 of 10  

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• INTRODUCTION
• CLINICAL
• DIFFERENTIALS
• WORKUP
• TREATMENT
• MEDICATION
• FOLLOW-UP
• Multimedia
• References

History

The itch of brachioradial pruritus is described as intense, burning, and prickling. It is localized to the dorsolateral aspects of the bilateral upper arms, forearms, and shoulders. Scratching is reported to make the discomfort worse, and many patients find that the only therapy that brings relief is the application of ice packs or cold, wet towels.^{3, 7, 16} The discomfort is typically worse at night and, for some patients, may interfere with falling asleep.⁴ The median duration of symptoms has been reported as 4.5 years,² but patients have reported a continuation of symptoms from this condition for as long as 18 years.¹

Physical

Despite the severity of symptoms, no associated erythema or skin eruption is seen. Evidence of excoriation or lichenification may be present in the affected areas.

Altered sensation to pinprick and temperature in the distribution of the posterior cutaneous nerve of the forearm, which supplies the skin over the proximal brachioradialis muscle, may be observed.⁶ Pronounced heat hyperalgesia in the C5 and C6 dermatomal distribution⁷ and pinprick hyperesthesia in the C5-C8 distribution⁸ may be seen.

Causes

Exposure of the affected areas to sun and wind may precipitate an episode, as may radiculopathy of the cervical spine. These are speculative, and the authors believe the etiology is multifactorial. In some cases, an emotional component to the symptoms seems apparent.

DIFFERENTIALS

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Other Problems to Be Considered

• Neurotic excoriations: Patients with brachioradial pruritus can excoriate the affected area, while the typical neurotic excoriation patient also has lesions on other accessible areas. An interface and a common etiology may exist between these 2 disorders.
• Notalgia paresthetica: This condition is typically associated with pruritus, pain, paresthesia, and hyperesthesia on the back.²² Often, a well-circumscribed hyperpigmented patch is present in the symptomatic area.
• Zoster sine herpete: This is an unusual manifestation of herpes zoster in which no cutaneous rash is observed. Unilateral paresthesias may be pronounced.
• Atopic dermatitis: Itch may be severe, although it usually involves flexor aspects of the elbows and is not associated with tingling. The Medscape Atopic Dermatitis Resource Center may be of interest.

WORKUP

Section 5 of 10  

• Authors and Editors
• INTRODUCTION
• CLINICAL
• DIFFERENTIALS
• WORKUP
• TREATMENT
• MEDICATION
• FOLLOW-UP
• Multimedia
• References

Lab Studies

If herpes zoster is suspected, consider direct immunofluorescence with fluorescein-tagged antibody or polymerase chain reaction studies to detect varicella-zoster virus.

Imaging Studies

Consider cervical spine imaging to rule out tumor or cervical rib and to evaluate for cervical radiculopathy.

Procedures

Electromyography or nerve conduction velocity studies may show delay of F responses of median and ulnar nerves and may assist in diagnosis in ambiguous cases.⁶

Histologic Findings

Biopsy of skin reveals atrophy and signs of sun damage, along with reduced numbers of both dermal and epidermal nerve fibers. Evidence exists that this reduction in cutaneous innervation occurs only during symptomatic flares, with innervation normalizing during symptom-free periods; thus, biopsy should ideally be performed when patients are actively experiencing symptoms.⁹

Staging

No staging system currently exists for brachioradial pruritus.

TREATMENT

Section 6 of 10  

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• WORKUP
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• MEDICATION
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• Multimedia
• References

Medical Care

Patients with brachioradial pruritus need time, sympathy, and understanding. They appreciate being told that they have a defined entity and that treatment options are available. Ice packs are helpful for immediate symptomatic relief, and other treatments can be tried in an outpatient setting. Frequent follow-up is often helpful emotionally for patients. Most cases remit in weeks to months.

Cervical nerve blocks have been reported to be unhelpful,⁷ but cervical spine manipulation is effective in some patients.^{1, 17} Cutaneous field stimulation has also been used. In one study, patients receiving 20 minutes of this treatment to affected areas once daily reported significant symptomatic improvement after 5 weeks.²⁴

Acupuncture may be helpful for symptomatic relief. Stellon²⁵ performed a retrospective case series of 16 patients with brachioradial pruritus using deep intramuscular stimulation acupuncture to the paravertebral muscles in the dermatomal segments of the body affected by the pruritus. Treatment was also given to other segments of the body not affected by the pruritus if paravertebral spasm and tenderness was detected. After a median of 4 treatments, 12 of 16 patients reported complete resolution of symptoms and 4 patients reported partial resolution. Relapse occurred in 6 patients within 1-12 months of cessation of acupuncture.

Surgical Care

Surgical care is generally not indicated unless the patient has a documented cervical radiculopathy, cervical rib, or fibrous band impinging on the brachial plexus.

Consultations

Relief after physical therapy has been reported in case series, so consultation with a physical therapist or a chiropractor may be considered, particularly in patients with radiographic evidence of cervical spinal disease. Heyl¹ reported a case of one patient whose brachioradial pruritus developed after a neck injury, and symptoms were relieved by neck traction.
 
The authors have not found consultation with a neurologist or pain specialist to be of value.

Consultation with an acupuncturist may be helpful.

Some patients have psychiatric disorders that predispose to brachioradial pruritus, while others may develop anxiety, depression, obsessions/compulsions, or delusions of parasitosis in response to the exasperating symptoms.

Diet

No dietary modifications have been reported to alleviate symptoms.

Activity

Patients who notice exacerbation of symptoms with sunlight exposure benefit from restricting their time outdoors during peak sunlight hours (10 am to 2 pm). Often, wearing long-sleeved shirts when outdoors provides relief equal to that achieved with more sophisticated interventions. Sunscreens are typically less effective.

MEDICATION

Section 7 of 10  

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• INTRODUCTION
• CLINICAL
• DIFFERENTIALS
• WORKUP
• TREATMENT
• MEDICATION
• FOLLOW-UP
• Multimedia
• References

Treatment of brachioradial pruritus remains a challenge. Most patients find relief with the application of cold packs that numb the skin; hence, a positive "ice-pack sign" is almost pathognomonic for this condition.³ Oral antihistamines and topical corticosteroids are only occasionally of value. If potent or superpotent topical corticosteroids are used, care must be taken to avoid cutaneous atrophy from overzealous use. Occasionally, patients are helped with topical anesthetics (eg, lidocaine cream or gel) or with 5% topical doxepin.

Substance P is a neurotransmitter important in the transmission of pain and itch neural signals. Topical capsaicin cream (0.025-0.05%) is a natural plant product that depletes substance P from cutaneous nerve endings.²⁶ It has been reported by a number of authors to provide relief of brachioradial pruritus within weeks,^{11, 15, 27, 28} although the authors have not found it to be useful in their patients.

Numerous oral medications have been tried with varying success. Case reports describe sustained symptomatic relief with gabapentin (1800 mg/d),²³ lamotrigine (200 mg/d),⁷ amitriptyline (25-150 mg qhs),¹⁵ and pimozide (1-2 mg/d). Oxcarbemazepine has proven effective in several patients reported by Savk and Savk.²² Risperidone has been used with some success in certain patients. No medication works predictably. When using psychotropic medications, obtaining a psychiatric opinion is advisable unless the treating physician commonly prescribes these agents.

Drug Category: Analgesic, Topical

Drug Category: Antianxiety Agent

Drug Category: Antiarrhythmic Agent, Class I-b

Drug Category: Anticonvulsant

Drug Category: Antidepressant, Tricyclic

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• INTRODUCTION
• CLINICAL
• DIFFERENTIALS
• WORKUP
• TREATMENT
• MEDICATION
• FOLLOW-UP
• Multimedia
• References

Further Outpatient Care

Frequent outpatient follow-up of patients with brachioradial pruritus is often helpful.

Deterrence/Prevention

Strict photoprotection with sunscreen and long-sleeved shirts can prevent recurrence of symptoms in some patients. The Medscape Skin Cancer Resource Center may be of interest.

Complications

Psychiatric symptoms (eg, anxiety, depression) may develop over time in patients with unremitting symptoms.

Prognosis

Most patients with brachioradial pruritus have remissions, but a small percentage have chronic disease. Emotional or psychiatric factors likely play a role in prognosis.

Patient Education

Education regarding sun protection and avoidance of peak sunlight hours is worthwhile.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• INTRODUCTION
• CLINICAL
• DIFFERENTIALS
• WORKUP
• TREATMENT
• MEDICATION
• FOLLOW-UP
• Multimedia
• References

Media file 1:  Area of pruritus demarcated in pen in a middle-aged woman with brachioradial pruritus. Macroscopically, no skin changes are visible.
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Media type:  Photo

Media file 2:  Subtle excoriations on the dorsal forearm of a middle-aged woman with brachioradial pruritus.
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Media type:  Photo

REFERENCES

Section 10 of 10

• Authors and Editors
• INTRODUCTION
• CLINICAL
• DIFFERENTIALS
• WORKUP
• TREATMENT
• MEDICATION
• FOLLOW-UP
• Multimedia
• References

1. Heyl T. Brachioradial pruritus. Arch Dermatol. Feb 1983;119(2):115-6. [Medline].
2. Veien NK, Hattel T, Laurberg G, Spaun E. Brachioradial pruritus. J Am Acad Dermatol. Apr 2001;44(4):704-5. [Medline].
3. Bernhard JD, Bordeaux JS. Medical pearl: the ice-pack sign in brachioradial pruritus. J Am Acad Dermatol. Jun 2005;52(6):1073. [Medline].
4. Waisman M. Solar pruritus of the elbows (brachioradial summer pruritus). Arch Dermatol. Nov 1968;98(5):481-5. [Medline].
5. Walcyk PJ, Elpern DJ. Brachioradial pruritus: a tropical dermopathy. Br J Dermatol. Aug 1986;115(2):177-80. [Medline].
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8. Fisher DA. Brachioradial pruritus wanted: a sure cause (and cure) for brachioradial pruritus. Int J Dermatol. Nov 1997;36(11):817-8. [Medline].
9. Wallengren J, Sundler F. Brachioradial pruritus is associated with a reduction in cutaneous innervation that normalizes during the symptom-free remissions. J Am Acad Dermatol. Jan 2005;52(1):142-5. [Medline].
10. Wallengren J, Dahlbäck K. Familial brachioradial pruritus. Br J Dermatol. Nov 2005;153(5):1016-8. [Medline].
11. Bech-Thomsen N, Thomsen K. Solar pruritus. Acta Derm Venereol. Nov 1995;75(6):488-9. [Medline].
12. Kestenbaum T, Kalivas J. Solar pruritus. Arch Dermatol. Nov 1979;115(11):1368. [Medline].
13. Orton DI, Wakelin SH, George SA. Brachioradial photopruritus--a rare chronic photodermatosis in Europe. Br J Dermatol. Sep 1996;135(3):486-7. [Medline].
14. Armstrong DK, Bingham EA. Brachioradial pruritus--an uncommon photodermatosis presenting in a temperate climate. Dermatology. 1997;195(4):414-5. [Medline].
15. Barry R, Rogers S. Brachioradial pruritus--an enigmatic entity. Clin Exp Dermatol. Nov 2004;29(6):637-8. [Medline].
16. Goodkin R, Wingard E, Bernhard JD. Brachioradial pruritus: cervical spine disease and neurogenic/neuropathic [corrected] pruritus. J Am Acad Dermatol. Apr 2003;48(4):521-4. [Medline].
17. Tait CP, Grigg E, Quirk CJ. Brachioradial pruritus and cervical spine manipulation. Australas J Dermatol. Aug 1998;39(3):168-70. [Medline].
18. Kavak A, Dosoglu M. Can a spinal cord tumor cause brachioradial pruritus?. J Am Acad Dermatol. Mar 2002;46(3):437-40. [Medline].
19. Rongioletti F. Pruritus as presenting sign of cervical rib. Lancet. Jan 4 1992;339(8784):55. [Medline].
20. Cohen AD, Masalha R, Medvedovsky E, Vardy DA. Brachioradial pruritus: a symptom of neuropathy. J Am Acad Dermatol. Jun 2003;48(6):825-8. [Medline].
21. Gore DR, Sepic SB, Gardner GM. Roentgenographic findings of the cervical spine in asymptomatic people. Spine. Jul-Aug 1986;11(6):521-4. [Medline].
22. Savk E, Savk SO. On brachioradial pruritus and notalgia paresthetica. J Am Acad Dermatol. May 2004;50(5):800-1. [Medline].
23. Kanitakis J. Brachioradial pruritus: report of a new case responding to gabapentin. Eur J Dermatol. May-Jun 2006;16(3):311-2. [Medline].
24. Wallengren J, Sundler F. Cutaneous field stimulation in the treatment of severe itch. Arch Dermatol. Oct 2001;137(10):1323-5. [Medline].
25. Stellon A. Neurogenic pruritus: an unrecognised problem? A retrospective case series of treatment by acupuncture. Acupunct Med. Dec 2002;20(4):186-90. [Medline].
26. Bernstein JE. Capsaicin and substance P. Clin Dermatol. Oct-Dec 1991;9(4):497-503. [Medline].
27. Goodless DR, Eaglstein WH. Brachioradial pruritus: treatment with topical capsaicin. J Am Acad Dermatol. Nov 1993;29(5 Pt 1):783-4. [Medline].
28. Knight TE, Hayashi T. Solar (brachioradial) pruritus--response to capsaicin cream. Int J Dermatol. Mar 1994;33(3):206-9. [Medline].
29. Fisher DA. Brachioradial pruritus: a recurrent solar dermopathy. J Am Acad Dermatol. Oct 1999;41(4):656-8. [Medline].
30. Wallengren J. Brachioradial pruritus: A recurrent solar dermopathy. J Am Acad Dermatol. Oct 1999;41(4):657-8. [Medline].

Article Last Updated: Apr 2, 2008
Topic originally published: Apr 2, 2008