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Scalp Dysesthesia Related to Cervical Spine Disease

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Scalp Dysesthesia Related to Cervical Spine Disease OBSERVATION ONLINE FIRST Scalp Dysesthesia Related to Cervical Spine Disease Laura A. Thornsberry, MD; Joseph C. English III, MD Background: Scalp dysesthesia is characterized by ab- mal imaging findings included anterolisthesis, osteo- normal sensations of the scalp in the absence of any other phytic spurring, lordosis, kyphosis, and nerve root im- unusual physical examination findings. The pathogen- pingement. A gabapentin regimen (topical or oral) had esis of this condition is unknown but has been reported been recommended to 14 patients; of 7 patients who were in the setting of underlying psychiatric disorders. Other followed up, 4 patients noted improvement in symp- localized pruritic syndromes, including brachioradial pru- toms when taking gabapentin. ritus and notalgia paresthetica, have been associated with pathologic conditions of the spine and have been suc- Conclusions: Patients with scalp dysesthesia also had cessfully treated with gabapentin. abnormal cervical spine images. Chronic muscle ten- sion placed on the pericranial muscles and scalp apo- Observations: Among 15 women identified in a ret- neurosis secondary to the underlying cervical spine dis- rospective review of medical records as having been seen ease may lead to the symptoms of scalp dysesthesia. with scalp dysesthesia, 14 patients had cervical spine dis- ease confirmed by imaging. The most common finding JAMA Dermatol. 2013;149(2):200-203. on imaging was degenerative disk disease, with 10 of 14 Published online November 19, 2012. patients having these changes at C5-C6. Other abnor- doi:10.1001/jamadermatol.2013.914 CALP DYSESTHESIA WAS FIRST sion correlating with the dermatomal dis- described by Hoss and Se- tribution of the pruritus. A case series3 of gal1 in 1998 as a cutaneous 10 patients with notalgia paresthetica dysesthesia syndrome char- showed a relationship between the loca- acterized by pruritus, burn- tion of the symptoms and the abnormal im- Sing, stinging, or pain of the scalp in the ages in 7 patients. The radiologic find- absence of any other unusual physical ex- ings in brachioradial pruritus and notalgia amination findings. In their case series of paresthetica prompted our study of cer- 11 patients, 5 patients had at least 1 known vical spine imaging in patients seen with psychiatric disorder (dysthymic disor- scalp dysesthesia. der, somatization disorder, or general- ized anxiety disorder), 7 patients had symp- REPORT OF CASES toms worsened by stress, and 9 patients had symptom improvement with low- 1 In our patients (Table), the most com- dose antidepressant treatment. Their study mon symptoms of scalp dysesthesia were did not examine underlying cervical spine burning (7 patients), pruritus (6 pa- disease among the patients. The patho- tients), or both burning and pruritus (2 genesis of scalp dysesthesia is poorly un- patients). Two patients described a sen- derstood and has not been determined. sation of “bugs crawling” on the scalp. Two Other localized pruritic syndromes, in- patients had concurrent chronic telogen cluding brachioradial pruritus and notal- effluvium, and 2 other patients reported gia paresthetica, have been associated with subjective hair loss that was not further de- pathologic conditions of the spine con- scribed in the medical records. Two pa- firmed by cervical and thoracic spine tients reported chronic neck pain, and 1 imaging studies.2-5 In a study2 of 41 pa- Author Affiliations: patient had a history of a C6-C7 fusion sur- Author Aff Department of Dermatology, tients with brachioradial pruritus, 29 pa- gical procedure. None of the patients had Departmen University of Pittsburgh, tients had abnormal magnetic resonance worsening or improvement of the symp- University Pittsburgh, Pennsylvania. (MR) images showing nerve compres- toms with certain head positions or exer- Pittsburgh, JAMA DERMATOL/ VOL 149 (NO. 2), FEB 2013 WWW.JAMADERM.COM 200 ©2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 Table. Patients With Scalp Dysesthesia and Cervical Spine Imaging Psychiatric Sex/Age, y Symptoms Diagnosis Cervical Spine Imaging Treatment and Outcome F/59 Pruritus of frontal and None MR imaging showed DDD at C4-C7 Gabapentin (100 mg 3 times daily) occipital scalp recommended chiropractic care, no follow-up data F/78 Burning on vertex None Radiography showed anterolisthesis of C5 Gabapentin (100 mg 3 times daily), controlled scalp, hair loss on C6, degenerative changes, symptoms (discontinued because of osteophytic spurring palpitations), completed physical therapy F/38 Pruritus, “bugs biting None Radiography showed reversal cervical Topical gabapentin, 10% (3 times daily), and crawling” lordosis, C5-C6 interspace narrowing provided no improvement in symptoms, sensation referred to neurology F/52 Pruritus diffusely None Radiography showed cervical kyphosis Topical gabapentin, 10% (3 times daily), centered at C5 with C5-C6 predominant provided partial response, completed DDD, MR imaging showed reversal of physical therapy normal cervical lordosis with central broad-based protrusion at C4-C5 F/65 Burning diffusely None Radiography showed mild DDD at C4-C7 Gabapentin (100 mg twice daily) and and moderate left and mild right C4-C5 venlafaxine hydrochloride (18.75 mg/d) foraminal narrowing, MR imaging provided no improvement in symptoms, showed mild multilevel degenerative topical clobetasol propionate provided partial changes (predominantly in the form of response, recommended physical therapy but neural foraminal narrowing) the patient refused, referred to neurology F/57 Pruritus, burning, None Radiography showed reversal of Gabapentin (oral) recommended but the patient “bugs crawling” curvature, advanced DDD at C5-C7 was unable to fill the prescription because of diffusely cost, referred to neurology, no follow-up data F/55 Burning diffusely None Radiography showed prior anterior fusion Topical gabapentin, 10% (3 times daily), no of the C6-C7 levels, moderate DDD at follow-up data C4-C6 F/65 Pruritus of occipital Depression Radiography showed severe DDD and Topical and oral gabapentin provided no scalp, hair loss narrowing between C5-C6 and C6-C7 improvement in symptoms, clobetasol propionate provided partial response F/50 Burning on right None Radiography showed mild DDD and Topical gabapentin, 10% (3 times daily), and parietal scalp narrowing at C5-C6 venlafaxine hydrochloride (50 mg/d) provided partial response F/74 Burning on vertex and None Radiography showed anterolisthesis of C6 Topical hydrocortisone provided partial temporal scalp on C7, moderate facet joint and response, referred to neurology uncovertebral arthrosis in the mid and lower cervical segments F/41 Burning on scalp and None MR imaging showed minimal DDD (most Gabapentin (100 mg 3 times daily) provided right arm, hair loss prominent at C6-C7), osteophyte partial response, gabapentin was increased to complex with tiny central protrusion 300 mg (3 times daily) (no follow-up data), referred to neurology, had normal electromyogram and nerve conduction study of the right arm F/62 Pruritus of scalp, Depression MR imaging showed arthritis and disk Amitriptyline hydrochloride (25 mg) provided eyebrows, disease (most significant at C5) partial response, gabapentin recommended nasolabial folds but the patient was unable to fill the prescription because of cost, referred to neurology F/83 Pruritus diffusely Anxiety Computed tomography showed mild to Topical gabapentin, 10% (3 times daily), no moderate multilevel spondyloar- follow-up data thropathy, C5-C6 posterocentral osteophyte resulting in spinal stenosis, impingement of left C6 F/78 Pruritus and burning None MR imaging showed cervical nerve root Topical gabapentin, 10% (3 times daily), no diffusely compression (full report not available) follow-up data F/72 Scalp burning None Radiography and MR imaging showed Gabapentin and amitriptyline recommended but diffusely, hair loss normal findings the patient declined, referred to neurology Abbreviations: DDD, degenerative disc disease; MR, magnetic resonance. cises. The symptoms were diffuse in 10 patients and were ethnicity, with an age range of 38 to 83 years. Two pa- localized to various regions of the scalp in 5 patients, in- tients had a diagnosis of depression, and 1 patient had a cluding the frontal, vertex, occipital, parietal, and tem- history of anxiety. None of the patients indicated that poral scalp. One patient with diffuse scalp burning also stress had any influence on their symptoms. The physi- reported burning in the right arm. The duration of symp- cal examinations were unremarkable for primary le- toms before presentation ranged from several months to sions, although 3 patients had secondary excoriations in 8 years. All 15 patients were women of white race/ the symptomatic areas of their scalps. The differential di- JAMA DERMATOL/ VOL 149 (NO. 2), FEB 2013 WWW.JAMADERM.COM 201 ©2013 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/23/2021 agnosis for scalp pruritus includes many common der- scalp dysesthesia and cervical spine disease, most com- matologic conditions, including seborrheic dermatitis, monly DDD. Scalp dysesthesia does not seem to follow psoriasis, scarring alopecia, tinea capitis, pediculosis, con- a dermatomal distribution given that the most common tact dermatitis, allergic dermatitis, acne, and folliculitis. location of DDD in our study was C5-C6. We hypoth- The physical examination has a crucial role in the diag-
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