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Brachioradial Pruritus
Authors

Blake A. Robbins1; George J. Schmieder2.

Affiliations
1 VCOM/OPMC
2 Orange Park

Last Update: September 12, 2022.

Continuing Education Activity

Brachioradial pruritus (BRP) is a localized neuropathic dysesthesia of the dorsolateral upper extremities. It is
commonly seen in middle-aged white females with a seasonal predilection for warmer summer months. Cervical
radiculopathy or neuropathy in the upper extremities in conjunction with ultraviolet radiation (UVR) are thought to be
causative. This activity describes the cause and pathophysiology of brachioradial pruritus and highlights the role of
the interprofessional team in its management.

Objectives:

Describe the cause of brachioradial pruritus.

Outline the evaluation of a patient with brachioradial pruritus.

Summarize the treatment options for brachioradial pruritus.

Review the importance of improving care coordination among interprofessional team members to improve
outcomes for patients affected by brachioradial pruritus.

Access free multiple choice questions on this topic.

Introduction
Brachioradial pruritus (BRP) is a localized neuropathic dysesthesia of the dorsolateral upper extremities. It is
commonly seen in middle-aged white females with a seasonal predilection for warmer summer months. Cervical
radiculopathy or neuropathy in the upper extremities in conjunction with ultraviolet radiation (UVR) are thought to be
causative.[1][2][3] Despite the wide variety of etiologies for pruritus, identification of brachioradial pruritus by
dermatologists through the history and physical exam has been straightforward. Further workup, such as imaging,
labs, and referral to specialists is rarely required. Therapeutic options are numerous and well-tolerated. Because of the
benign transient nature of brachioradial pruritus, the number of reported cases and current studies are relatively low.

Etiology
While not completely elucidated, current theories suggest brachioradial pruritus is a bifactorial process involving
cervical nerve irritation and ultraviolet radiation (UVR) of the affected area.[4][5][6]

A large majority of patients diagnosed with brachioradial pruritus will have a positive imaging study with evidence of
one or more cervical spine abnormalities. Imaging with x-ray computed tomography (CT) or magnetic resonance
imaging (MRI) of patients with suspected or diagnosed brachioradial pruritus revealed cervical spine abnormalities
such as degenerative joint disease (DJD), cervical nerve impingement due to disk herniation, osteoarthritis, foraminal
stenosis, and others. DJD has been reported as the most common cervical spine abnormality in patients with
brachioradial pruritus. Many authors suggest that cervical spine disease between C5 to C8 is causative. The
dermatomes of the dorsolateral arms are C5 to C6, and a cervical spine abnormality with evidence of radiculopathy at
these levels would be especially suggestive as a cause for brachioradial pruritus. Despite the high frequency of
cervical spine abnormalities on imaging, nearly all brachioradial pruritus patients imaged did not meet the criteria for
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cervical radiculopathy. Additionally, only a minority of patients diagnosed with brachioradial pruritus are imaged.
This suggests that cervical radiculopathy not inclusive of radiologic criteria may be responsible for the high frequency
of cervical spinal abnormalities in patients with brachioradial pruritus may simply be a confounding finding.

UVR is thought to be a contributing factor of brachioradial pruritus, and many patients report increased symptoms of
brachioradial pruritus with sun exposure. The term brachioradial summer pruritus is also used in reference to the
increased incidence of brachioradial pruritus during the warm summer months. A subset of histamine sensitive C-
fibers is responsible for the transmission of pruritus. Excessive UVR causes damage and a reduction of these C-fibers.
Despite the reduction in cutaneous C-fiber number, increased pruritus is reported with UVR in patients with
brachioradial pruritus. This pruritic response to a stimulus that does not normally cause pruritus is known as
alloknesis. Many patients report relief of symptoms during the winter months and with sun protection, which supports
the role of UVR as a trigger in brachioradial pruritus.

The absence of either radiographically evident cervical nerve irritation or UVR does not preclude the diagnosis of
brachioradial pruritus.

Epidemiology
Early isolated case reports suggested that brachioradial pruritus was more common in males. Later larger studies
revealed that brachioradial pruritus is seen more commonly in females than males in a ratio 3:1. The mean age at
diagnosis is 59, but wide variations in age have been reported. Brachioradial pruritus is more common in lighter skin
types, especially those with Fitzpatrick type I and type II skin, than in darker skin types. This factor further supports
the role of UVR in the pathogenesis of brachioradial pruritus.

Histopathology
Brachioradial pruritus lacks characteristic histopathological features. Microscopic findings include actinic elastosis
and decreased density of epidermal and dermal nerve fibers. Actinic elastosis correlates with a history of extensive
UVR exposure. A decrease in the density of nerve fibers is seen with phototherapy treatments and would be consistent
with UVR-induced brachioradial pruritus exacerbations during the sunny summer months.

History and Physical

Because pruritus has many etiologies, a thorough history is essential to avoid unnecessary testing and delay in
treatment. Brachioradial pruritus has a wide area of presentation but is most commonly reported on the dorsolateral
arms. Adjacent areas that may be affected are in the C5 to C6 dermatome and include the upper arms, shoulders, and
neck. In addition to pruritus, patients may report pain, stinging, or tingling in the affected area.
Brachioradial pruritus is bilateral approximately 75% of the time. [7][8][9]Symptoms are usually present for 2 to 3
years before diagnosis. Patients are typically outdoor enthusiasts such as bikers, hikers, and tanners and may have an
extensive history of sunburn. Despite the high frequency of cervical spine abnormalities seen on imaging in patients
with brachioradial pruritus, retrospective studies report that very few patients had complaints of neck pain, cervical
spine narrowing, or neck trauma.

The physical exam of the affected areas is not impressive and lacks primary cutaneous lesions. Secondary cutaneous
lesions such as excoriations, prurigo nodules, or lichenification may be present due to excessive scratching.

Confounding factors include coexistent chronic pruritic conditions, skin diseases, topical or systemic medications, and
unusual presentations.

Evaluation
The ice-pack sign is considered pathognomonic for brachioradial pruritus. The test is simple and involves placing an
ice-pack to the affected area. The patient should report immediate improvement of pruritus that returns shortly after
the removal of the ice-pack.

Evaluations beyond a thorough history and physical and the ice-pack test are typically unnecessary. Imaging, blood
tests, and referrals to appropriate specialists may be required in recalcitrant cases. Imaging modalities such as x-ray,
CT, and MRI usually are not required. If imaging of the cervical spine is desired, MRI is the preferred modality.
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Screening blood work for causes of chronic pruritus can be performed. Referral to neurology for further examinations
may be appropriate if a neurological cause is suspected. Neurological examinations include cervical spine imaging
and electromyography (EMG).

Treatment / Management
Treatment includes avoidance of UVR, topical medications, systemic medications and in select cases, surgery.

Methods of UVR avoidance include reducing sun exposure, judicious use of sunscreen, and use of long-sleeved UV-
protective clothing. This may be difficult for some patients with brachioradial pruritus, as many enjoy outdoor
activities during the warm summer season. Topical medications include capsaicin, mild steroids, anesthetics,
antihistamines, and amitriptyline/ketamine. Earlier reports stated topical capsaicin was the most commonly prescribed
initial therapy. A newer study reported the oral tricyclic antidepressant, amitriptyline, was the most commonly
prescribed medication for brachioradial pruritus, although gabapentin may be more efficacious.

Other oral medications include risperidone, fluoxetine, chlorpromazine, and hydroxyzine. For unknown reasons,
systemic antihistamine therapies are ineffective in brachioradial pruritus. Response to treatment was greatest in
patients who rated their pruritus as severe and those that continued with longer treatments. [10][11][12]It should be
noted that the sample size of most studies are small and differences in the most prescribed and efficacious therapy
vary. Surgery was reserved for patients with a correctable cervical spinal abnormality seen on imaging. Very few
patients fall into this category.

Differential Diagnosis

Neurotic excoriations

Notalgia paresthetica

Zoster sine herpete

Atopic dermatitis

Enhancing Healthcare Team Outcomes

The diagnosis and management of BRP are very difficult and thus it is managed by an interprofessional team that
includes a neurologist, hand surgeon, dermatologist, nurse practitioner, primary care provider, internist, psychiatrist,
and specialty trained nurses. Communications between these professionals will improve the coordination of care.
Specialty trained nurses in dermatology, pain management, and psychiatry may be involved.

The condition is more common in middle-aged white females with a seasonal predilection for warmer summer
months. Cervical radiculopathy or neuropathy in the upper extremities in conjunction with ultraviolet radiation (UVR)
are thought to be causative.There are hundreds of treatment for the disorder but none works reliably or is better than
other treatments. Patients go through exhaustive workup to determine the cause, which is never found in most cases.
Many patients develop severe anxiety, depression and become isolated. In these cases, a mental health consultant
physician and specialty-trained nurse should be included in the team. The pharmacist and nurse should educate the
patient in the management of pain and pruritus. In addition, the patient should be told to avoid exposure to the sun,
wear long-sleeved garments and keep the skin moisturized. Finally, referral to a pain specialist may be in order if the
pain is constant and can vary from moderate to severe.

The condition is benign but it can seriously affect the quality of life because of the constant itching.[13][3] [Level V]

Review Questions

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Comment on this article.

References

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8. Strowd RE, Strowd LC, Blakeley JO. Cutaneous manifestations in neuro-oncology: clinically relevant tumor and
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9. Salako KB, Anstey AA, Logan RA. Delayed, transient, postsolar truncal pruritus: a report of two cases. Clin Exp
Dermatol. 2014 Aug;39(6):726-7. [PubMed: 24986101]
10. Pereira MP, Lüling H, Dieckhöfer A, Steinke S, Zeidler C, Agelopoulos K, Ständer S. Application of an 8%
capsaicin patch normalizes epidermal TRPV1 expression but not the decreased intraepidermal nerve fibre
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[PubMed: 29427475]
11. Wachholz PA, Masuda PY, Pinto ACVD, Martelli ACC. Impact of drug therapy on brachioradial pruritus. An
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12. Zeidler C, Lüling H, Dieckhöfer A, Osada N, Schedel F, Steinke S, Augustin M, Ständer S. Capsaicin 8%
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Disclosure: Blake Robbins declares no relevant financial relationships with ineligible companies.

Disclosure: George Schmieder declares no relevant financial relationships with ineligible companies.

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Figures

Brachoradialis pruritus

Image courtesy O.Chaigasame

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