Medical Pearl: The ice-pack sign in brachioradial pruritus

Abstract

Patients with brachioradial pruritus (BRP) often report that their itch feels “deep,” that scratching only makes it worse, and that the only thing that provides any relief is the application of ice packs, chilling the skin to the point of numbness. 1 Goodkin R. Wingard E. Bernhard J.D. Brachioradial pruritus: Cervical spine disease and neurogenic/neuropathic pruritus. J Am Acad Dermatol. 2003; 48: 521-524 Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar The ice-pack sign is nearly pathognomonic for this condition. The weight of available evidence suggests that BRP is a neurogenic/neuropathic itch. 2 Cohen A.D. Masaalha R. Medvedowvsky E. Vardy D.A. Brachioradial pruritus: A symptom of neuropathy. J Am Acad Dermatol. 2003; 48: 825-828 Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar , 3 Wallengren J. Sundler F. Brachioradial pruritus is associated with a reduction in cutaneous innervation that normalizes during the symptom-free remissions. J Am Acad Dermtol. 2005; 52: 142-145 Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar It usually presents with a picking, prickling, burning, or just plain itchy itch of one or both forearms. BRP can involve, or “spread,” to the upper arms as well (especially the lateral aspects). It occasionally spreads across the upper back, and very occasionally across the neck and uppermost chest. In some patients, sunlight acts as a trigger. Despite offering temporary relief, it is also possible that ice-pack application may be counterproductive, but this remains to be determined. There are anecdotal reports that treatment with oral gabapentin may be helpful in treating some patients with severe BRP. 4 Winhoven S.M. Coulson I.H. Bottomley W.W. Brachioradial pruritus: response to treatment with gabapentin. Br J Dermatol. 2004; 150: 786-787 Crossref PubMed Scopus (90) Google Scholar