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Brachioradial Pruritus: An Etiologic Review and Treatment Summary

Cutis. 2023 August;112(2):84-87 | doi:10.12788/cutis.0828
August 3, 2023|Dermatology
Kathryn J. Kavanagh, DC;Peter L. Mattei, MD;Ryan Lawrence, BS;Colin Burnette, BS
Author and Disclosure Information

Drs. Kavanagh and Mattei are from the US Department of Veterans Affairs, Veteran Health Administration, Bay Pines VA Healthcare System, Cape Coral, Florida. Ryan Lawrence is from the Palmer College of Chiropractic West Campus, San Jose, California. Colin Burnette is from the Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Florida. 

The authors report no conflict of interest.

Correspondence: Kathryn J. Kavanagh, DC, 2489 Diplomat Pkwy E, Cape Coral, FL 33909 (kathryn.kavanagh@va.gov). 

Brachioradial pruritus (BRP) is a relatively uncommon neuropathic dysesthesia localized to the dorsolateral arms that causes unrelenting itching, burning, tingling, or stinging sensations. There is no identifiable cause of BRP to date, though it is thought to be secondary to either cervical spine pathology or exposure to UV radiation (UVR). Gold-standard treatment of BRP remains unknown. This article reviews previously trialed conservative management options, including chiropractic manipulation, acupuncture, physiotherapy, and photoprotection, as well as medical management options that have been utilized to treat BRP, such as medications, interventional pain management procedures, and surgery. We compiled an updated comprehensive list of possible treatment strategies to be utilized by future providers.

Practice Points 

  • The etiology of brachioradial pruritus (BRP) has been associated with cervical spine pathology and/or UV radiation exposure. 
  • Treatment options for BRP range from conservative to invasive, and clinicians should consider the evidence for all options to decide what is best for each patient.

Medical Treatment

Medication—Because of the nonspecific clinical presentation of BRP, initial treatment often involves prescription of first-line antipruritic agents, including steroid creams and systemic antihistamines, both of which generally fail to provide symptom relief.1,30 Medications with neurologic mechanisms of action appear to provide potentially superior outcomes. Neuroleptics, including gabapentin and pregabalin, are typical therapeutic agents for neurogenic pruritus and inhibit nociceptive pain propagation.31 Intervention with pregabalin in 3 patients with BRP achieved complete symptom relief in all patients, with initial improvement occurring in as little as 1 week.8 Mirogabalin, operating under a similar mechanism, has shown preliminary success in treating BRP, causing anecdotal patient improvement within 4 months of initial dosage.32 Prolonged 1-month intravenous naloxone treatment also appars to be promising, offering symptom improvement of at least 80% six months posttreatment.15 

Topical interventions for BRP and related neurogenic pruritus have shown limited success. A case series evaluating capsaicin for pruritus offered only transient relief, likely because of its temporary hyperstimulatory and desensitizing effect on neuropeptides.7,33 In small populations, the use of topical antidepressants has yielded cutaneous and pathological relief for BRP. A case study of a 70-year-old woman evaluated the efficacy of a combination cream of ketamine and amitriptyline (a tricyclic antidepressant) yielding moderate pruritus improvement and notable improvement of secondary brachial skin lesions.34 Oral steroids also have shown success in the treatment of chronic pruritus; however, limited research is available on the efficacy of such medications for BRP, and the long-term use of oral steroids is limited by many side effects.30 

Interventional Pain Procedure—A 2018 case series investigated 3 patients with a clinical diagnosis of BRP who were treated between 2010 and 2016 with epidural steroid injection using computed tomography guidance of the cervical spine.35 The authors reported that 2 patients had near-complete resolution after 1 interventional procedure. The third patient had a total of 3 injections, with mild to moderate relief that continued to improve on mexiletine.35 Another case in 2010 of a 56-year-old man with BRP documented use of a series of 2 epidural steroid injections that resulted in clinical resolution of symptoms.36

Surgery—There are multiple case studies in the literature that discuss anterior cervical discectomy and fusion (ACDF) as a last resort in patients with refractory BRP of discogenic cause. In 2022, Morosanu et al37 described a case of a 63-year-old woman with BRP in the C5–C6 distribution who had an associated disc protrusion at this level following magnetic resonance imaging. The patient underwent a C5/C6 ACDF after conservative and medical treatment failed, and at 3-month follow up her symptoms had resolved entirely.37 Another case report described a 56-year-old man who ultimately underwent ACDF after failed multimodal treatment attempts, with instant improvement in symptoms. Four months after surgery, the patient reported a 95% improvement of symptoms.19 An older case in 2008 discussed the use of ACDF in a 64-year-old woman with severe distress and an identifiable surgical target. The patient’s symptoms resolved completely within 1 week after surgery.10

Conclusion 

The pathogenesis of BRP continues to be an area of debate—it may be secondary to cervical spine disease or UVR. This review found there is more research pointing to cervical spine disease. There is an abundance of literature discussing both conservative and invasive treatment strategies, both of which carry benefits. Further research is needed to better establish the etiology of BRP so that formal treatment guidelines may be established. 

Neuropathic itch can be a frustrating condition for providers and patients, and many treatment modalities often are tried before arriving at a helpful treatment for a particular patient. Clinicians who may encounter BRP in practice benefit from up-to-date literature reviews that provide a summary of management strategies.

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