Thoughts about brachioradial pruritus

Brachioradial pruritus is a common condition that is not well-recognized by most practitioners. I saw my first patient with brachioradial pruritus (BRP) in 1983 when I practiced dermatology in Hawaii.  She was a middle-aged woman with intractable pruritus over the dorsolateral (brachioradial) aspect of her left arm proximal and distal to the elbow.  I remember her well since an article on the subject had recently appeared in the Archives of Dermatology1.  Her general doctor had told her it was “nerves” and prescribed amytriptylene, which at the time was primarily an antidepressant.

BRP is more commonly encountered in tropical and sub-tropical areas, and over the next few years I saw a fair number of cases on Kauai, Hawaii2.  On a few occasions I even experienced it myself, mostly after I had a few days off and spent time driving in Hawaii, my left arm out of car window.  The episodes I experienced were short-lived and I have not experienced it since moving to Massachusetts in 1993.

There are two main theories as to the etiology of BRP.

  1. That it is a photodermatitis.
  2. That it is neurogenic and results from nerve impingement in the cervical spine.

It may be a combination of these factors as it does appear to be more common in sunny climes.  In spite of the research that has been done, there is a lot we still have to learn about BRP.  Most cases are probably mild, such as the episodes I experienced, and a few are intractable, lasting months to years.  This may be related to how we perceive sensations of itch.  Patients with BRP commonly complain of intense itching, as if small needles are being inserted into the affected skin, and many pick at the affected area causing excoriations.

In 2000, Dr. Henry Foong and I started a teledermatology site called Virtual Grand Rounds in Dermatology  (VGRD)3, and we presented a case of BRP in January of 20014.  This elicited a few comments from practitioners.  In late 2004, we established the VGRD blog5 to make it easier for others to post cases and  presented another case of BRP in 20116.  At the time of this writing, we have had over 100 comments on the BRP post, almost all from patients.  The heightened interest most likely is related to the nature of search engines and the public’s growing facility with surfing the World Wide Web.  This VGRD-Blog post has far and away the most comments of the greater than 350 pages on that site.

It is clear that worldwide many people suffer with severe BRP and that large numbers of them do not find knowledgeable practitioners.  The Internet provides an opportunity for a small number of BRP patients to communicate their distress and frustration.  Such was the case with Patricia Myersfield whose article appears in the International Journal of Userr Driven Healthcare7.  She stumbled on the VGRD blog post5 and in the spirit of sharing contributed her fine essay.  Her words will be instructive to all who read them.

What should one recommend to a patient with BRP or to a health care professional dealing with these patients?

1) The review article8 written by Julianne Mann is an excellent place to start.

2) An article9 by Desire Gijima, a medical student at the Mayo Clinic, details and discusses the comments made from many patients to VGRD blog.

3) Pat Myersfield’s article is invaluable, as well.

 

The etiology of BRP is still in question, however, exposure to ultraviolet light and wind may be important factors for many of these patients.  I have not found that neck x-rays or imaging techniques have helped many patients.  Persons who develop BRP are of an age where most people will have some cervical spine arthritis as it is.

From a therapeutic standpoint, here is what I have gleaned over the past 30 years of dealing with these patients.

1.  If it seems likely that sun and wind play a role, long sleeved shirts are worth try.

2. Ice packs to affected limbs, two to there times a day, afford relief to many sufferers.  An inexpensive approach is to use bags of peas from the freezer or reusable packs such as Cold Comfort from 3M.

3. Silk sleeves may help some of these patients.10

4. Acupuncture can help selected patients if the practitioner is familiar with this disorder11.

5.  Chiropractic has been anecdotally recommended.

6. Gabapentin and Lyrica can be considered12

7.  Mirror box therapy may have a role for recalcitrant cases13.

 

Most patients will improve over a few weeks to months.  Persons with recalcitrant disease will benefit from consulting with a knowledgeable provider who communicates that BRP is a recognized entity and not some mysterious affliction that is likely to last indefinitely.   As with other orphan patients14 who have poorly understood diseases,  “Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine15.”

If you are suffering from Brachioradial Pruritus simple steps you can take include:

1. If it seems likely that sun and wind play a role, long sleeved shirts are worth try.

2. Ice packs to affected limbs, two to there times a day for twenty minutes, afford relief to many sufferers. An inexpensive approach is to use bags of peas from the freezer or reusable packs such as Cold Comfort from 3M (costs ~ $2.50 USD)

3. Silk sleeves may help some of these patients. Can get these from DermaSilk.

4. Acupuncture can help selected patients if the practitioner is familiar with this disorder.

5. Chiropractic has been anecdotally recommended.

6. Gabapentin and Lyrica can be considered. These have some side-effects and are not for mild cases.

 

References:

1. Heyl T.  Brachioradial pruritus. Arch Dermatol. 1983 Feb;119(2):115-6.

2. Walcyk PJ, Elpern DJ. Brachioradial pruritus: a tropical dermopathy.  Br J Dermatol. 1986 Aug;115(2):177-80.

3. Virtual Grand Rounds in Dermatology  http://www/vgrd.org

4. http://www.vgrd.org/archive/cases/2001/brachioradial/brachioradial.html

5. VGRD Blog.  http://www.vgrd.blogspot.com

6. http://www.vgrd.blogspot.com/search/label/Brachioradial%20Pruritus

7. Myersfield P.  My Journey with Brachioradial Pruritus.  Int. J User Driven Healthcare (in press)

8.  Mann J. Brachioradial Pruritus. eMedicine.  http://emedicine.medscape.com/article/1355312-treatment#a1128

9. Gijima D., Elpern DJ.  Int. J. User Driven Health Care (in press)

10.  DermaSilk Therapeutic Clothing.  http://www.dermasilk.ca/

11. Stellon A. Neurogenic pruritus: an unrecognised problem? A retrospective case series of treatment by acupuncture. Acupunct Med. 2002 Dec;20(4):186-90.

12. Kanatakis J. Brachioradial pruritus: report of a new case responding to gabapentin.

European Journal of Dermatology. Volume 16, Number 3, May-June 2006, Correspondence (Available Free Full Text)

13. Lamont K, Chin M, Kogan M. Mirror box therapy: seeing is believing. Explore (NY). 2011 Nov-Dec;7(6):369-72. doi: 10.1016/j.explore.2011.08.002.

14.  Shelley WB, Shelley ED.  The orphan patient. N Engl J Med. 1988 Mar 10;318(10):646.

15. Peabody FW. Landmark article March 19, 1927: The care of the patient. By Francis W. Peabody. JAMA. 1984 Aug 10;252(6):813-8.

 

 

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2 comments on “Thoughts about brachioradial pruritus

  1. Laura RObertson on said:

    Thank you so much for this work. I have suffered from the symptoms of BRP for years, at times feeling hopeless to find a doctor who was willing to listen to my complaints of symptoms (and they are very specific). Thankfully for me (probably not the doctor) the internet allowed me to search for information and find articles such as yours. I am currently going through another round of itching and have been self-treating with a menthol 1% and Pramoxine hydrochloride 1% cream, ice and nightly Benadryl. At least it allows me to sleep and not scratch my shoulder bloody. I hope to see more a common awareness raised about this. It may help people like me who suffer in silence thinking a doctor who tells us it’s all in our heads is right, which is humiliating.

  2. I’ve had BRP for about 5 years. Cervical traction with a home device (used in a horizontal body position) seems to relieve some of the pressure on cervical nerves. In addition, Lidocaine 5% patches (manufactured by Watson/Actavis Pharmaceuticals) placed each evening on shoulders and arms have provided significant, beneficial, and effective relief. Patches are worn for 12 hours and help the patient to sleep at night. The benefits seem to carry over into the following day. Lastly, Aspercream with 4% Lidocaine provides on-the-spot short term relief. Effective hygiene includes cool or cold showers with only Cetaphil used on arms and shoulders.

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