What it is

➝ Neuropathic itch is chronic pruritus caused by damage or dysfunction of the peripheral or central nervous system, rather than skin inflammation.

➝ It can occur in conditions such as post-herpetic neuralgia, notalgia paresthetica, brachioradial pruritus, diabetic neuropathy, multiple sclerosis, stroke, or spinal cord disease.

➝ Gabapentinoids (gabapentin and pregabalin) are anticonvulsant drugs that modulate calcium channels in neurons, reducing abnormal excitability and transmission of itch signals.

➝ In Korea, gabapentinoids are widely used in dermatology, neurology, and pain clinics for chronic neuropathic itch syndromes.

Why it’s done

→ To relieve intense, treatment-resistant itching that does not respond to antihistamines or topical steroids.

→ To improve sleep and quality of life, since neuropathic itch is often worse at night.

→ To prevent secondary skin damage (excoriations, lichenification, scarring) from scratching.

→ To manage itch in complex systemic or neurological conditions where standard dermatologic treatments fail.

Alternatives

→ Topical therapies: capsaicin, lidocaine patches, pramoxine, menthol.
→ Antidepressants: mirtazapine, amitriptyline, doxepin.
→ Opioid modulators: naltrexone, butorphanol in selected refractory cases.
→ Phototherapy: NB-UVB, excimer laser for localized neuropathic itch.
→ Biologics/JAK inhibitors: mainly for inflammatory itch, less effective in pure neuropathic syndromes.

Preparation

→ Detailed history and exam to confirm neuropathic cause of itch (burning, tingling, localized distribution, association with neurological disease).

→ Baseline labs (renal and liver function) since gabapentinoids are renally excreted.

→ Patient counseling about gradual titration, possible drowsiness, dizziness, and need for long-term use.

→ In Korea, physicians often perform neurology consultation and imaging (MRI spine/brain) if structural pathology is suspected.

How it’s Done

→ Gabapentin

• Start: 100–300 mg at night.
• Titrate slowly every 3–7 days.
• Typical dose: 900–1800 mg/day in divided doses (sometimes up to 3600 mg).

→ Pregabalin

• Start: 25–50 mg at night.
• Increase to 75–150 mg twice daily.
• Usual range: 150–300 mg/day; max 600 mg/day if tolerated.

→ Both drugs are given orally and require gradual dose escalation to reduce side effects.

→ Combination with topical therapy (capsaicin, lidocaine) is common for localized itch.

→ In Korea, physicians often prescribe pregabalin more frequently due to its predictable absorption and simpler dosing schedule.

Recovery

→ Patients often notice partial relief within 1–2 weeks, with maximum effect after 4–6 weeks of titration.

→ Neuropathic itch intensity may decrease by 50–70%, improving sleep and mood.

→ Long-term therapy is usually required, with dose adjustments depending on recurrence.

Complications

→ Common side effects: drowsiness, dizziness, unsteadiness, peripheral edema, weight gain.
→ Rare: blurred vision, mood changes, withdrawal symptoms if stopped abruptly.
→ Elderly patients: higher risk of sedation and falls, requiring cautious dosing.
→ Requires dose adjustment in renal impairment.

Treatment Options in Korea

→ Korean dermatology and neurology clinics widely prescribe gabapentin and pregabalin as standard therapy for neuropathic itch.

→ Pregabalin is often favored for brachioradial pruritus, notalgia paresthetica, and post-herpetic neuralgia, while gabapentin is used for widespread or systemic neuropathic itch.

→ Major hospitals integrate gabapentinoids with physical therapy, phototherapy, or topical anesthetics for multimodal management.

→ Patients are monitored closely for side effects, especially elderly individuals, with regular follow-ups every 4–8 weeks.

→ Korean clinical practice emphasizes patient education and gradual titration, ensuring adherence and minimizing risks.