# Botulinum Toxin Treatment of Notalgia Paresthetica—A Critical Review and Update

## TL;DR

This paper reviews the use of botulinum toxin for treating Notalgia Paresthetica, a skin condition causing itching and pain in the upper back.

## Contribution

The novelty is a comprehensive and critical review including new data not covered in previous studies.

## Key findings

- Only one of eight studies was double-blind and placebo-controlled, while others were open-label.
- Open-label studies showed improvement in itching, but the blinded study did not.
- The review highlights the need for larger, controlled trials using consistent toxin types.

## Abstract

Notalgia paresthetica is a condition characterized by pruritus and pain in the upper back, often associated with skin discoloration in the same area. Through Medline, Google Scholar, and Scopus search engines, we identified reports of eight clinical studies (published up to 1 December 2025) on the subject of botulinum neurotoxin therapy for Notalgia Paresthetica (NP). Only one of the eight studies was double-blind and placebo-controlled. The search strategy included only articles published in English and Spanish, and articles providing basic information such as the type of study, type and dose of the toxin, and results of the treatment. Articles not in English or Spanish, review articles, and articles failing basic information were excluded. A total of 34 patients were found across all studies. The injected toxin in the open-label studies was onabotulinumtoxin-A (Botox), whereas in the blinded study, the investigators used incobotulinumtoxinA (Xeomin). All open-label studies reported improvement in pruritus, and some reported improvement in pain, whereas the blinded study failed to do so. The possible reasons for this discrepancy between the blinded and the open-label studies are discussed. There is a need for double-blind, placebo-controlled studies with a larger number of patients, preferably using the same neurotoxin that has suggested efficacy in the open-label studies. The novelty of this review is that it represents a comprehensive and critical literature assessment on this topic and that it includes data not present in the previous reviews of this subject.