BRP, which stands for brachioradial pruritus, is a neuropathic condition affecting the dorsolateral upper extremities. As compared to males, it is more commonly found in middle-aged females. The main causative factors for Brachioradial Pruiritis include etiologies like ultraviolet radiation, cervical radiculopathy, and upper extremities neuropathy. Even though there are many reasons for brachioradial pruritus, a thorough history and physical examination by a dermatology expert can be identified. Histopathologic examination of this neurogenic condition shows a lack of any characteristic features. The microscopic evaluation and neurology studies may show a lower density of epidermal, degenerative changes in the dermal nerve fibres, and actinic elastosis. (1) (2) (3)
Aetiology and Pathophysiology of Brachioradial Pruritus
Studies suggest that brachiocephalic pruritus is caused by a bifactorial mechanism, which involves the irritation of the cervical nerve root and ultraviolet therapy of the affected area. The imaging studies like X-rays, Ct scans, and Magnetic resonance imaging also show cervical spine abnormalities. The cervical spine diseases seen in Brachioradial pruritus are usually caused by cervical nerve impingement, disk herniation, foramen stenosis, and osteoarthritis. Service spine disease at the level of c5, c6, c7, and c8 may also be a cause of this condition. Experts believe a major cause of cervical spine abnormality is the involvement of the C5 and C6 dorsolateral dermatomes. (4) (5) (6)
Similar to the changes caused by ultraviolet radiation therapy, increased sun exposure may also lead to the pathology of brachioradial Pruritis. In fact, this is so common that brachioradial Pruritis is also referred to as brachioradial summer pruritus due to the high sun exposure during these warm months. Individuals in the winter months and those that use sun protection often find relief from the symptoms of nerve endings irritation, as seen in brachioradial Pruritis. (7)
Symptoms of Brachioradial Pruritus and Itchy Neck
According to the British Journal of Dermatology (Br J Dermatol) and Journal of Americal Academy of Dermatology (J Am Acad Dermatol) main areas that are affected by Brachioradial Pruritus include the neck, upper arms, and shoulders due to the involvement of the C5 and C6 dermatome. Other than itching and prurigo, individuals may also experience symptoms like pain, stinging, and tingling. Moreover, these symptoms may be unilateral, but they are found to be bilateral in 75% of the cases. The diagnosis of brachioradial Pruritis is not commonly made before the patient has been experiencing symptoms for 2 to 3 years. These symptoms are also frequently seen in people with a higher sun exposure indulging in more outdoor activities. These individuals are usually hikers, bikers, and athletes. Some people may also report the presence of lesions like pruritic nodules and excoriations due to scratching the affected area. (8) (9) (10)
Diagnosis of Brachioradial Pruritus
One of the pathognomic features which can be used for the diagnosis of Brachioradial Pruritis is the ice pack sign. This test involves the application of an ice pack to the affected area. For the period of the ice pack placement, the patient with Brachioradial Pruiritis may report improvement in symptoms. However, these symptoms return once the ice pack is removed. While a history, physical examination, and ice pack test are enough for the diagnosis of this condition, some clinicians may also recommend imaging and lab works. The imaging techniques which are most commonly used for its diagnosis include Magnetic Resonance Imaging (MRI) of the cervical spine, for which CT and X-rays are usually not required. Other than imaging, lab work like blood tests may also be used as a screening tool for Brachioradial Pruritus. If the healthcare physician suspects a neurological complication, they may also refer the patient to a neurologist.
The treatment options recommended by a dermatologist for Brachioradial pruritus include systemic drug therapy, topical ointments and creams, acupuncture, and avoiding sun exposure and ultraviolet radiation.
The ultraviolet radiation can be avoided by avoiding the sun altogether or using high-quality sunscreen. Avoiding the sun may be difficult for individuals who like to indulge in outdoor activities or who have a job that requires them to be out in the sun most of the day or in warmer climates.
The topical creams which may be recommended for the improvement of symptoms include Capsaicin cream, antihistamines, steroids, anaesthetics, amitriptyline, ketamine, and menthol. However, experts believe that while starting an ointment-based treatment for Brachioradial Pruritus, the individual may start with Capsaicin.
The oral medications that may be recommended for Brachioradial Pruiritis include Amitriptyline, Gabapentin, Doxepin, Lamotrigine, and Pregabalin. Antihistamine therapies at a systemic level may not be as effective for Brachioradal Pruritis as their topical therapy. While the recommendation of surgery is rare, it may be required for individuals with cervical spine abnormality that cannot be corrected by medications and physical therapy alone. (11) (12) (13)
The Differential Diagnosis of Brachoradial Pruritus and Itchy Neck
While conducting diagnostic studies, Brachiradual Pruritis may be confused with a number of other conditions. These include Notalgia Paresthesthetica, Atopic Dermatitis, Neurotoc Excoriations, and Herpes Zoster.
Complication Of Brachioradial Pruritus
The possible complications associated with Brachiradial PRuitirs if a medical intervention if not take on time include:
· Loss of skin pigmentation
· Formation of hard lumps on the affected area
· Darkening of the skin of the affected area
· Thickening of the skin of the affected area
· Formation of rough patches
· Formation of sores
How can you Prevent Brachioradial Pruritus?
In order to reduce the risk of Brachioradial Pruritus, the individual may lower their sun exposure, wear protective clothing while going out, and use sunscreen throughout the day with an SPF of at least 30.
Who is at Risk of Developing Brachioradial Pruritus?
Individuals who are at particularly high risk for brachioradial Pruritis include those who are:
· Having a higher sun exposure
· Having neck problems
· Having back problems
Prognosis of Brachioradial Pruritus and Itchy Neck
Individuals with brachioradial pruritus may experience symptoms for a few weeks or a few months, after which these symptoms usually go away. This is particularly true for individuals who take medications or reduce their exposure to sunlight. However, while some individuals report their symptoms sot to be completely resolved, others might experience these symptoms reappearing after short intervals all their life.
What causes Brachioradial pruritus to flare up?
The two main risk factors which may lead to the flaring up of Brachioradial pruritus include Increase exposure to the sun and the presence of spinal abnormalities. The ultraviolet radiation from the sun can lead to the development of brachioradial pruritus; hence it may be found more often in individuals with jobs that require them to be outdoors. Moreover, the presence of spinal abnormalities like herniated discs, spinal compression, and osteoarthritis may also trigger brachioradial pruritus flare-up. This is because this condition often leads to the compression of the nerve roots affecting the upper extremities of the body like the arms.
Is Brachioradial pruritus rare?
Brachioradial pruritus is not a common condition and may only be experienced by a small percentage of individuals. It is characterized by itching on the dorsolateral part of the upper extremities like shoulders, arms, and neck. Although rare, it is more often found in females as compared to males, according to later case series. The ratio of females to males being affected by this condition is found to be 3:1. The age that is most often associated with the diagnosis of this condition is 59, particularly in individuals who have a lighter skin tone.
Does it get worse at night?
The itching, burning, or prickling feeling associated with Brachioradial pruritus may get worse at night. Other factors which may contribute to its worsening include warm climate, sun exposure, and wind.
Does pruritus ever go away?
While mild cases of Brachioradial pruritus may heal over time and go away on their own, on the other hand, treating it using oral medication and topical creams may accelerate the healing process and lead to less discomfort for the individual during the healing period. The healing period for Brachioradial pruritus is found to be between a few weeks to a few months, depending on the patient’s unique case.
What does a neuropathic itch feel like?
A majority of the people with Brachioradial pruritus explain the neuropathic itch associated with it to feel like pins and needles being inserted into their skin at the affected area. The intensity of the itching may range from mild to severe. It may also be associated with a feeling of burning.
How do you get rid of Brachioradial pruritus?
The treatment most commonly prescribed for Brachioradial pruritus include ice pack application, physical therapy, over-the-counter medications, creams containing menthol and Capsaicin, and even surgery in severe cases. While ice packs and menthol-containing creams may provide a cooling effect to the affected area and reduce the inflammation and itch, physical therapy is recommended to strengthen the spine and improve any abnormalities causing the condition. Some individuals with extreme symptoms and feelings of burning may be recommended local anaesthetic creams, which will help improve the pain in the affected area. These local pain killers may also include Ketamine and Amitriptyline. Moreover, the oral medications that are most commonly prescribed for Brachioradial pruritus are usually anti-inflammatory in nature. They may include content like Amitrotyline, Gabapentine, Doxepin, Lamotrigine and Pregabalin.
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