Patient Case


Easy. Common

56-year-old woman. She reports the appearance of an itchy patch on her back. She has applied an antifungal and a topical steroid without success.

Pigmented/pruritic macule in the dorsal paravertebral region.


Most likely diagnosis: notalgia paresthetica.

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Notalgia paresthetica

Notalgia paresthetica is a common cause of localized itching on the back. Although the reason for consultation is often a skin patch, the underlying problem is not primarily dermatological, but neuropathic.

It results from irritation, compression, or entrapment of dorsal sensory branches. This may be related to muscle contractures, postural abnormalities, or degenerative changes in the spine and discs that affect these roots or nerves.

Key point: skin changes are usually secondary to scratching or repeated manipulation, not to a fungal infection.

Why can it be mistaken for something else?

Patients often present because of a patch on the back, and topical treatments such as antifungals or corticosteroids are often tried initially. However, in notalgia paresthetica, these treatments do not produce a response unless the neuropathic and musculoskeletal component is addressed.

The lesion may resemble dermatitis, ringworm, or an inflammatory patch, but there are clinical clues that point to the diagnosis.

Clinical clues

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Symptoms

Itching, burning, tingling, or numbness.

Skin lesion

Pigmented macule with ill-defined borders and no scaling.

Location

Paravertebral region, especially over the thoracic spine. It may be unilateral or bilateral.

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How to recognize it in the clinic

Clinical finding What it suggests
Localized itching on the back Typical symptom of neuropathic origin.
Poorly defined pigmented patch Usually due to chronic scratching or manipulation.
Absence of scaling Makes a superficial fungal infection less likely.
Failure of antifungal or corticosteroid treatment Should prompt consideration of causes that are neither infectious nor primarily inflammatory.
Dorsal paravertebral location Highly characteristic of notalgia paresthetica.

Practical diagnosis

The key is to recognize that the visible skin lesion is the consequence of the symptom: itching or dysesthesia of neuropathic origin.

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1
Itching or burning

Localized, recurrent, and bothersome symptom.

2
Repeated scratching

Causes initial erythema, pigmentation, or excoriations.

3
Dorsal macule

Pigmented, poorly defined, and without scaling.

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Management

Treatment may include pharmacological options for the neuropathic component, but the most important aspect is usually to address associated musculoskeletal factors.

Local and pharmacological measures

  • Topical capsaicin.
  • Oral pregabalin in selected cases.
  • Oral gabapentin in selected cases.

Most important

  • Improve posture.
  • Perform pectoral and back stretches.
  • Strengthen the paravertebral muscles.
  • Consider physiotherapy.
  • Exercises such as Pilates or swimming may help.
  • If the patient is overweight, weight reduction may be beneficial.

Take-home message

Notalgia paresthetica is not a fungal infection or a primary dermatitis. It is a localized neuropathic disorder: the skin changes because the patient scratches or manipulates the area.

Final summary

  • Common: a common cause of localized itching on the back.
  • Neuropathic: related to irritation or entrapment of dorsal sensory branches.
  • Typical clinical features: itching, burning, tingling, or numbness.
  • Lesion: pigmented, poorly defined macule, usually without scaling.
  • Location: dorsal paravertebral region, unilateral or bilateral.
  • Management: capsaicin, gabapentin, or pregabalin in some cases, but above all posture, stretching, strengthening, and physiotherapy.

When faced with an itchy dorsal patch that does not respond to antifungal or corticosteroid treatment, think of notalgia paresthetica.

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