What does it mean if your perfectly healthy skin is marred by invisible, incurable itching? If the unbearable itching is limited to the arms, it means you might have neuropathic brachioradial pruritus—a condition that’s far more frustrating than this riddle implies. By the time these patients come into your pharmacy, they’re exhausted from itch-induced insomnia and desperate for relief. They may not know it yet, but they need expert advice, as typical OTC itch-relief products won’t be effective. Pharmacists who find a way to reach out can guide patients’ treatment choice and help them understand the nature of this disease.
Overview of Neuropathic Brachioradial Pruritus
Brachioradial pruritus was once thought to be isolated to tropical climates, but it’s also found in more temperate locations. In the United States, cases have been reported in such diverse regions as Massachusetts, Florida, Kansas, and California.1 It has a simple definition—it’s a neurogenic itch syndrome of the arms, often localized to the forearm but sometimes involving the upper arms—yet treatment is anything but easy.
The most common cause of brachioradial pruritus is nerve root compression.2 Magnetic resonance tomography showed cervical nerve compression in 80.5 percent of patients, according to a study in the Journal of the American Academy of Dermatology in October 2011.3 These patients didn’t have neck pain; their only symptom was itchy skin downstream from the compressed nerve. The remaining patients in the study had degenerative changes in the spine that didn’t correlate to the dermatomal localization of their pruritus. While multimodal causes are likely at play in some patients, brachioradial pruritus is not well studied, so further research is needed to nail down answers.
The study, which included 41 patients diagnosed with brachioradial pruritus, also reported the following:
Skin biopsies showed normal, healthy skin except for changes like leathering and scratch marks, caused by chronic scratching.
Itching started in the dermatome of the nerves at cervical vertebra 6, which corresponds to the outside surface of the forearms over the brachioradial muscle.
Both arms were affected in about half of the participants.
What Pharmacists Need to Know for Patient Counseling
The itching caused by brachioradial pruritus has characteristics that are different from the itching associated with common skin conditions, which is one of the most frustrating factors for patients who try to self-treat. Even though the symptoms usually go into remission within a few months, this doesn’t mean patients are cured. They’ll have to cope with the condition for an average of 5 years—and some will have it as long as 18 years. Here’s a rundown of what patients with brachioradial pruritus experience:
The itch is intense 24/7 and is often accompanied by burning and stinging sensations.
The itching gets worse at night.
Scratching only makes the itch worse.
Touching sometimes makes it worse.
Warmth, heat, sunlight, and wind worsen symptoms.
When patients face unremitting symptoms over an extended period of time, they’re at risk for developing anxiety and depression, so this aspect of the disease must also be addressed. People need to know it’s normal for the itching to take a toll on their emotions and sense of well-being. While more research is needed to verify the role of psychiatric factors, experts believe that emotional health does influence the prognosis. Be prepared with basic information about the signs of depression, and encourage patients to seek professional support.
Treatment Options for Brachioradial Pruritus
Basic care to keep skin well hydrated is important, especially since brachioradial pruritus primarily occurs between the ages of 40 to 60, when the skin is already likely to be dehydrated. All patients should be advised to protect their arms from sunlight, as it usually exacerbates symptoms. The itching remits within a few months for most patients, but in the meantime, the best relief is obtained by applying ice packs to the affected areas. Unfortunately, this treatment is limited because most people can’t keep a cold compress on their arms at work. They need other options. Your patients can try:
Topical medications
Capsaicin – an 8 percent topical capsaicin patch is well tolerated; the duration of itch relief varies from a few days to several months
Lidocaine
Menthol / camphor
Doxepin cream – especially effective at bedtime
Tacrolimus
A compounded mixture of amitriptyline hydrochloride 1.0 percent, ketamine hydrochloride 0.5 percent, and Vanicream – applied 2-3 times daily, this mixture relieved all symptoms in a patient with a five-year history of brachioradial pruritus.
Oral medications
Common medications used for most types of itching, such as antihistamines and corticosteroids, usually aren’t effective for a neuropathic itch. None of the oral agents work predictably in all patients, but these have proven to be occasionally effective:
Gabapentin
Amitriptyline
Doxepin
Lamotrigine
Oxcarbemazepine
Risperidone
A recent review of 49 patients with brachioradial pruritus found that 80 percent had symptom relief with monotherapy using tricyclic antidepressants, doxepin, or antipsychotics.4 However, most treatment recommendations come from isolated case studies.
Alternative therapies
Deep intramuscular stimulation acupuncture, transcutaneous electrical nerve stimulation, and physical therapy may help some patients.5
Topical Treatment Advice Improves Outcomes
While they’re waiting for symptoms to remit, patients with brachioradial pruritus must make it through the day and keep up with their responsibilities despite the discomfort and distraction of a relentless itch. Pharmacists can work with each individual to find the topical agent—or compounded mixture of active pharmaceuticals—that provides the most effective relief. You’ll also need to help patients find products to improve sleep, whether that’s a stronger topical agent or an OTC product like melatonin. Your expertise makes all the difference for these patients, who are in it for the long haul.
Pharmaceutica North America provides high-quality bulk APIs, compounding kits, and prescription drug products—including topical lidocaine—to help patients with brachioradial pruritus. Contact us today to talk about how we can support all your pharmaceutical needs.
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