Brachioradial Pruritus

Background

This disease is probably underreported and typically occurs in a middle-aged woman, living in a temperate climate, who experiences tingling, burning, and pruritus on the dorsal aspects of the forearms, possibly also on the lateral aspects of the upper arms and the shoulders. The lesions do not occur on sun protected areas.

OUTLINE

Epidemiology

Disease Associations

Pathogenesis

Laboratory/Radiologic/
Other Diagnostic Testing

Gross Appearance and Clinical Variants

Histopathological Features and Variants

Special Stains/
Immunohistochemistry/
Electron Microscopy

Differential Diagnosis

Prognosis

Treatment

Commonly Used Terms

Internet Links

EPIDEMIOLOGY CHARACTERIZATION

SYNONYMS Actinic brachioradial neuralgia
Solar pruritis

AGE RANGE-MEDIAN 40-60s

SEX (M:F)
Women more common

GEOGRAPHY
August to December

DISEASE ASSOCIATIONS CHARACTERIZATION

NEUROPATHY/SPINAL DISEASE/SPINAL CORD TUMOR

Brachioradial pruritus: A symptom of neuropathy.

Cohen AD, Masalha R, Medvedovsky E, Vardy DA.

Departments of Dermatology and Neurology, Soroka University Medical Center; Dermatology Institute, Clalit Health Services, Southern District; and Faculty of Health Sciences, Ben-Gurion University of the Negev.

J Am Acad Dermatol. 2003 Jun;48(6):825-8. Abstract quote
BACKGROUND: Brachioradial pruritus (BRP) is a localized pruritus of the dorsolateral aspect of the arm. BRP is an enigmatic condition with a controversial cause; some authors consider BRP to be a photodermatosis whereas other authors attribute BRP to compression of cervical nerve roots.

OBJECTIVE: We sought to investigate the presence of neuropathy in patients with BRP.

METHODS: We performed electrophysiologic studies of the median, ulnar, and radial nerves in consecutive patients with BRP, including measurement of sensory and motor distal latency, conduction velocity and F responses of the median and ulnar nerves, and sensory distal latency of the radial nerves in both upper limbs.

RESULTS: Included in the study were 7 patients, 5 men and 2 women, with an average age of 58.3 years (range: 42-72 years). Of the patients, 4 (57%) had abnormal F responses that were diagnostic for cervical radiculopathy, and 3 of these patients had prolonged distal latencies of the nerves tested, which may be interpreted as sensory motor neuropathy secondary to chronic radiculopathy. The fourth patient had polyneuropathy secondary to diabetes mellitus.

CONCLUSION: BRP may be attributed to a neuropathy, such as chronic cervical radiculopathy. The possibility of an underlying neuropathy should be considered in the evaluation and treatment of all patients with BRP.

Brachioradial pruritus: Cervical spine disease and neurogenic/neurogenic pruritus.

Goodkin R, Wingard E, Bernhard JD.

Division of Dermatology, University of Massachusetts Memorial Medical Center and Medical School.
J Am Acad Dermatol 2003 Apr;48(4):521-4 Abstract quote
BACKGROUND: The main cause of brachioradial pruritus (BRP) is not known but there is evidence to suggest that BRP may arise in the nervous system. Cervical spine disease may be an important contributing factor.

OBJECTIVE: Our aim was to determine whether spine pathology is associated with BRP.

METHODS: Medical charts of patients with BRP seen in the Division of Dermatology of the University of Massachusetts Medical Center between the years of 1993 and 2000 were retrospectively analyzed. On the basis of clinical index of suspicion, some patients had undergone radiography of the spine.

RESULTS: Of 22 patients with BRP, 11 had cervical spine radiographs. The radiographs showed cervical nnspine disease that could be correlated with the location of pruritus in each of these 11 patients.

CONCLUSIONS: Patients with BRP may have underlying cervical spine pathology. Whether this association is causal or coincidental remains to be determined.

Can a spinal cord tumor cause brachioradial pruritus?

Ayse Kavak, MD
Murat Dosoglu, MD

Duzce, Turkey J Am Acad Dermatol 2002;46:437-40 Abstract quote

A woman had burning pruritus on both arms and thenar regions for 1 year. The location of pruritus was consistent with C5-C6 dermatomes. Brachioradial pruritus caused by spinal cord tumor was diagnosed.

Although cases of brachioradial pruritus were reported in cervical osteoarthritis and cervical rib previously, to our knowledge, our patient is the first reported case of brachioradial pruritus caused by a tumor.

PATHOGENESIS

Brachioradial pruritus is associated with a reduction in cutaneous innervation that normalizes during the symptom-free remissions.

Wallengren J, Sundler F.

Department of Dermatology, University Hospital, Lund, Sweden.

J Am Acad Dermatol. 2005 Jan;52(1):142-5. Abstract quote

BACKGROUND: There has been a controversy regarding the cause of brachioradial pruritus: is it caused by a nerve compression in the cervical spine or is it caused by a prolonged exposure to sunlight?

OBJECTIVE: The purpose was to study clinical features of patients with brachioradial pruritus and to compare the cutaneous innervation in punch biopsies from the itchy skin of patients with the age-matched controls.

METHODS: Skin biopsy specimens from itchy skin of 16 patients with brachioradial pruritus were collected during the early autumn and were compared with corresponding skin specimens from 11 age-matched controls in the early spring, four of the patients being their own controls. The cutaneous innervation was visualized by antibodies against protein gene product 9.5 (general neuronal marker), by antibodies against calcitonin gene-related peptide (marker for thin sensory nerve fibers), and by antibodies against VR1-receptor (marker for capsaicin-sensitive nerve fibers).

RESULTS: In all but two of the patients, itching of the arms or shoulders was seasonal. Some patients reported neck pain. In the skin of the lower arm, the number of protein gene product 9.5 immunoreactive nerve fibers was reduced 23% as compared with controls ( P = .03), the number of intraepithelial nerve fibers being reduced by 27% ( P = .03). The number of calcitonin gene-related peptide immunoreactive nerve fibers in the dermis was reduced by 34% ( P = .02) and the number of capsaicin-sensitive nerve fibers by 43% ( P = .008). The innervation of the four patients who were their own controls became normalized during the symptom-free period.

CONCLUSIONS: The temporal course of the brachioradial pruritus and the histological changes in the skin similar to those caused by ultraviolet light, indicate that sunlight is an eliciting factor and that cervical spine disease can be a predisposing factor.

LABORATORY/
RADIOLOGY CHARACTERIZATION

ICE PACK SIGN The application of an ice pack, chilling the skin to numbness, is sometimes the only treatment that can provide relief. This finding is nearly pathognomonic for this condition.

Medical pearl: the ice-pack sign in brachioradial pruritus.

Bernhard JD, Bordeaux JS.

Department of Dermatology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.

J Am Acad Dermatol. 2005 Jun;52(6):1073. Abstract quote

HISTOLOGICAL TYPES CHARACTERIZATION

General Solar elastosis with scattered mast cells

PROGNOSIS AND TREATMENT CHARACTERIZATION

TREATMENT

Solar (brachioradial) pruritus: response to capsaicin cream.

Knight TE, Hayashi T.
Int J Dermatol 1994;33:206-9.

Gabapentin treatment for brachioradial pruritus.

Bueller HA, Bernhard JD, Dubroff LM.
J Eur Acad Dermatol Venereol 1999;13:227-8.

Br J Dermatol 1986;115:177-80.
Br J Dermatol 1996;135:486-7.
Dermatology 1977;195:414-5.
J Am Acad Dermatol 2001;44:704-5
Macpherson and Pincus. Clinical Diagnosis and Management by Laboratory Methods. Twentyfirst Edition. WB Saunders. 2006.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.

Commonly Used Terms

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Commonly Used Terms
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Diagnostic Process
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Surgical Pathology Report
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Special Stains
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Last Updated February 26, 2007

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DISEASE ASSOCIATIONS	CHARACTERIZATION
NEUROPATHY/SPINAL DISEASE/SPINAL CORD TUMOR
Brachioradial pruritus: A symptom of neuropathy. Cohen AD, Masalha R, Medvedovsky E, Vardy DA. Departments of Dermatology and Neurology, Soroka University Medical Center; Dermatology Institute, Clalit Health Services, Southern District; and Faculty of Health Sciences, Ben-Gurion University of the Negev.	J Am Acad Dermatol. 2003 Jun;48(6):825-8. Abstract quote BACKGROUND: Brachioradial pruritus (BRP) is a localized pruritus of the dorsolateral aspect of the arm. BRP is an enigmatic condition with a controversial cause; some authors consider BRP to be a photodermatosis whereas other authors attribute BRP to compression of cervical nerve roots. OBJECTIVE: We sought to investigate the presence of neuropathy in patients with BRP. METHODS: We performed electrophysiologic studies of the median, ulnar, and radial nerves in consecutive patients with BRP, including measurement of sensory and motor distal latency, conduction velocity and F responses of the median and ulnar nerves, and sensory distal latency of the radial nerves in both upper limbs. RESULTS: Included in the study were 7 patients, 5 men and 2 women, with an average age of 58.3 years (range: 42-72 years). Of the patients, 4 (57%) had abnormal F responses that were diagnostic for cervical radiculopathy, and 3 of these patients had prolonged distal latencies of the nerves tested, which may be interpreted as sensory motor neuropathy secondary to chronic radiculopathy. The fourth patient had polyneuropathy secondary to diabetes mellitus. CONCLUSION: BRP may be attributed to a neuropathy, such as chronic cervical radiculopathy. The possibility of an underlying neuropathy should be considered in the evaluation and treatment of all patients with BRP.
Brachioradial pruritus: Cervical spine disease and neurogenic/neurogenic pruritus. Goodkin R, Wingard E, Bernhard JD. Division of Dermatology, University of Massachusetts Memorial Medical Center and Medical School.	J Am Acad Dermatol 2003 Apr;48(4):521-4 Abstract quote BACKGROUND: The main cause of brachioradial pruritus (BRP) is not known but there is evidence to suggest that BRP may arise in the nervous system. Cervical spine disease may be an important contributing factor. OBJECTIVE: Our aim was to determine whether spine pathology is associated with BRP. METHODS: Medical charts of patients with BRP seen in the Division of Dermatology of the University of Massachusetts Medical Center between the years of 1993 and 2000 were retrospectively analyzed. On the basis of clinical index of suspicion, some patients had undergone radiography of the spine. RESULTS: Of 22 patients with BRP, 11 had cervical spine radiographs. The radiographs showed cervical nnspine disease that could be correlated with the location of pruritus in each of these 11 patients. CONCLUSIONS: Patients with BRP may have underlying cervical spine pathology. Whether this association is causal or coincidental remains to be determined.
Can a spinal cord tumor cause brachioradial pruritus? Ayse Kavak, MD Murat Dosoglu, MD Duzce, Turkey	J Am Acad Dermatol 2002;46:437-40 Abstract quote A woman had burning pruritus on both arms and thenar regions for 1 year. The location of pruritus was consistent with C5-C6 dermatomes. Brachioradial pruritus caused by spinal cord tumor was diagnosed. Although cases of brachioradial pruritus were reported in cervical osteoarthritis and cervical rib previously, to our knowledge, our patient is the first reported case of brachioradial pruritus caused by a tumor.

Epidemiology
Disease Associations
Pathogenesis
Laboratory/Radiologic/ Other Diagnostic Testing
Gross Appearance and Clinical Variants
Histopathological Features and Variants
Special Stains/ Immunohistochemistry/ Electron Microscopy
Differential Diagnosis
Prognosis
Treatment
Commonly Used Terms
Internet Links

EPIDEMIOLOGY	CHARACTERIZATION
SYNONYMS	Actinic brachioradial neuralgia Solar pruritis
AGE RANGE-MEDIAN	40-60s
SEX (M:F)	Women more common
GEOGRAPHY	August to December

HISTOLOGICAL TYPES	CHARACTERIZATION
General	Solar elastosis with scattered mast cells

PROGNOSIS AND TREATMENT	CHARACTERIZATION
TREATMENT
Solar (brachioradial) pruritus: response to capsaicin cream. Knight TE, Hayashi T.	Int J Dermatol 1994;33:206-9.
Gabapentin treatment for brachioradial pruritus. Bueller HA, Bernhard JD, Dubroff LM.	J Eur Acad Dermatol Venereol 1999;13:227-8.