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What Caused This Refractory Unilateral Pruritic Hyperpigmented Eruption?

What Caused This Refractory Unilateral Pruritic Hyperpigmented Eruption?

Our Patient
Our patient had seen no less than seven prior dermatologists over nearly as many years, and she reported failed treatments with flurandrenolide tape, intralesional triamcinolone, more than 30 sessions of phototherapy, potent topical steroids, and oral antihistamines.DermDx Figure 4

On the patient’s first visit, based on clinical acumen of a unilateral dermatomal eruption and a provisional diagnosis of atypical low spine NP/MP (Figures 1 and 2), the following workup was efficiently undertaken. A spinal MRI demonstrated a L5-S1 tear of the posterior annulus fibrous, with a 4.5-mm central disc protrusion, compression of the traversing S1 nerve roots, and moderate to severe stenosis, as well as a L4-L5 tear, with a 5-mm broad-based left paracentral disc protrusion and severe stenosis with questionable compression of the traversing left L5 nerve roots (Figure 3).

DermDx Figure 5Laboratory evaluation included a battery of pruritus serology tests, which demonstrated multiple newly diagnosed autoantibodies, leading to a rheumatologic referral. A novel multimodal therapy program, consisting of TENS and EMS, acupuncture, narrowband UV-B phototherapy, physical therapy, infrared phototherapy, oral hydroxyzine for breakthrough pruritus, and intralesional cortisone for any refractory prurigo nodules, was prescribed. This combination therapy resulted in near complete clearance of symptoms and cutaneous lesions at the second month (Figures 4 and 5).

Anatomy
Figure 6
depicts the anatomic rationale for the diagnosis and treatment of our patient based on the identification of the appropriate nerve root and corresponding affected dermatomes.11 This figure11 illustrates spinal dermatomes of the L4-S1 spinal nerves extending to the medial knee, medial calf, and dorsal medial midfoot as shown in the preceding figures. 

DermDx Figure 6

Conclusion 
The striking association of spinal paresthesias or SISS with degenerative, traumatic, or muscle-tension cervicolumbar spine disease suggests that spinal arthropathy or myalgia often contribute to the pathogenesis of the skin symptoms of NP, BRP, and MP.1-5 These localized pruritus conditions affect all ages from young adults to the elderly. Thus, a timely paradigm shift in the dermatologist’s global assessment and approach to these diseases with therapies aimed at the spine, most commonly the fifth through sixth cervical vertebrae and the fourth lumbar through first sacral vertebrae is deemed necessary.1-3 This highlights the author’s pearl of “treat the spine, and the skin will follow”.


Note: Spinal paresthesia, spinal paresthetica, and SISS are three new terms coined by this author and can be used interchangeably to encompass the continuum of spinal diseases including NP, BRP, MP, burning scrotum syndrome, and burning scalp.

Dr Alai is the medical director at The Skin & Wellness Center in Laguna Hills, CA, and a former associate professor at the University of California, Irvine.

Disclosure: The author reports no relevant financial relationships.  

References
1. Alai NN, Skinner HB, Nabili ST, Jeffes E, Shahrokni S, Saemi AM. Notalgia paresthetica associated with cervical spinal stenosis and cervicothoracic disk disease at C4 through C7. Cutis. 2010;85(2):77-81. 

2. Alai NN, Skinner HB. Concurrent notalgia paresthetica and brachioradial pruritus associated with cervical degenerative disc disease. Cutis. 2018;102(3):185-186, 189-190.

3. Goodkin R, Wingard E, Bernhard JD. Brachioradial pruritus: cervical spine disease and neurogenic/neuropathic pruritus. J Am Acad Dermatol. 2003;48(4):521-524. doi:10.1067/mjd.2003.203 

4. Şavk E, Şavk ŞÖ. On brachioradial pruritus and notalgia paresthetica. J Am Acad Dermatol. 2004;50(5):800-801. doi:10.1016/j.jaad.2003.07.022

5. Şavk E, Şavk Ö, Bolukbasi O, et al. Notalgia paresthetica: a study on pathogenesis. Int J Dermatol. 2000;39(10):754-759. doi:10.1046/j.1365-4362.2000.00080.x

6. Alai AN. Notalgia paresthetica. Medscape. https://emedicine.medscape.com/article/1599159-overview. Published July 10, 2018. Accessed January 3, 2020.

7. Dehghanian PM, Alai NN. What caused this refractory pruritic eruption? The Dermatologist. 2016;24(9):47-50.  

8. Paresthesia information page. National Institute of Neurological Disorders. https://www.ninds.nih.gov/Disorders/All-Disorders/Paresthesia-Information-Page. Published June 14, 2018. Accessed January 3, 2020.

9. Şavk E, Şavk Ö, Sendur F. Transcutaneous electrical nerve stimulation offers partial relief in notalgia paresthetica patients with a relevant spinal pathology. J Dermatol. 2007;34(5):315-319. doi:10.1111/j.1346-8138.2007.00279.x

10. Thornsberry LA, English JC 3rd. Scalp dysesthesia related to cervical spine disease. JAMA Dermatol. 2013;149(2):200-203. doi:10.1001/jamadermatol.2013.914

11. File: Grant 1962 663.png. Wikimedia Commons. https://commons.wikimedia.org/w/index.php?curid=30017222. Published December 5, 2013. Accessed January 6, 2020. 

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