By Gary M. White, MD
The patient put calamine lotion on the area of itch!
Brachioradial pruritus (BRP), also known as solar pruritus of the elbows, is a term used to describe itching along the photoexposed parts of the arm. It is most common during the fourth through sixth decades of life, with equal distribution between men and women. It is most common in the tropics. Some have suggested solar pruritus or actinic brachioradial neuralgia [JAAD 44;705] to emphasize the photoinduced aspect of this disease. Most cases of BP seem to be sun-induced but others may be related to a neuropathy.
Pruritus along the extensor forearm on one side is characteristic. Occasionally, both sides are affected. It is often worse in the summer with sunlight exposure. The classic patient is a professional driver whose arm hangs out the window while driving, but any adult may be affected. In a report of 8 patients [JAAD 2013], BRP seemed to be the cause of more generalized itching. Various studies have tried to link BRP to cervical spine disease, but an extensive workup seems to reveal such a connection in the minority--26% in one study [BJD 2013;169;1007].
Long sleeved shirts to shield the arm from the sun may completely clear the symptoms, e.g. in 6 weeks. Interestingly, broad spectrum sunscreens seem not to be as helpful. Application of anything cold relieves symptoms and this may be helpful in diagnosis, the so called "ice-pack sign". Various anecdotes and case reports (and a few small series) suggest possible interventions as outlined below.
Topical doxepin may be tried (caution drowsiness). A medium to high potency topical steroid may be given. In one report, cetirizine completely controlled a patient's symptoms.
Gabapentin 300 mg TID produced a marked benefit in various patients [Gabapentin treatment for brachioradial pruritus. J Eur Acad Dermatol Venereol 1999; 13:227–8].
The topical capsacian 8% patch (Qutenza) has been reported helpful. The patch is FDA approved in the US for post herpetic neuralgia. A one time application of the patch gave relief for up to 5-6 weeks [BJD 2015;17;1669]. From that article: "The patch was applied exactly to the itchy area for 60 minutes after pretreatment with topical lidocaine 2·5% containing emollient for 60 min. All patients reported burning pain during the application which lasted for up to 12 h (average 5·2 ± 4·0 h; median 4 h). Directly after removal of the patch, the skin showed self-limited erythema."
The compounded formulation of amitriptyline hydrochloride, 1%, in combination with ketamine hydrochloride, 0.5%, in a skin-moisturizing cream (Vanicream; Pharmaceutical Specialties Inc) to be applied to the affected area 2 to 3 times per day has been reported effective anecdotally [JAMA Dermatol. 2013;149(2):148-150].
Aprepitant, 80 mg/d, for 7 days was useful in once case [JAMA Dermatol. 2013;149:627-628].
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