NOTALGIA PARESTHETICA: CASE REPORT ON THERAPEUTIC MANAGEMENT WITH ULTRASOUND-GUIDED OZONE MESOTHERAPY

S. Sorrenti¹, M. Ciuffreda¹, E. Pisello¹, C. Pellegrino², A. Monacelli², G. Cucè⁴, C. Piangatelli¹, D. Galante⁴ | ¹Department of Anesthesiology, Intensive Care and Pain Management, AST Ancona, Fabriano (AN), Italy; ²Department of Anesthesiology, Intensive Care and Pain Management, Marche Polytechnic University, Ancona, Italy; ³Department of Public Health, University of Messina, Italy; ⁴Department of Anesthesiology, Intensive Care and Pain Management, ASL Foggia, Cerignola (FG), Italy

Background and Aims. Notalgia Paresthetica (NP) is a chronic neuropathic pruritus typically localized to the medial or inferior scapular region and often associated with burning pain or dysesthesia. Although considered relatively common, it remains underrecognized and frequently undertreated. Its pathogenesis is not fully clarified and is likely multifactorial, involving thoracic polyradiculopathy (T2–T6), peripheral nerve entrapment, degenerative vertebral changes, and muscular factors contributing to sensory nerve irritation. Conventional antipruritic therapies, including antihistamines and topical corticosteroids, generally provide limited benefit, as they do not address the underlying neuropathic mechanisms. Ozone therapy is known for its anti-inflammatory, analgesic, and bioregulatory properties and may also exert a mechanical effect by reducing nerve impingement through tissue diffusion. The aim of this case report is to evaluate the clinical effectiveness and feasibility of ultrasound-guided ozone mesotherapy in the management of symptomatic notalgia paresthetica refractory to standard topical treatment.
Methods. A patient diagnosed with Notalgia Paresthetica presenting with severe localized pruritus (WI-NRS 8) and burning pain in the left infrascapular region (approximately 4 cm²) was treated with ultrasound-guided ozone mesotherapy after failure of topical corticosteroid therapy. The procedure was performed with the patient seated. A high-resolution linear ultrasound probe was used to identify skin layers and measure dermal depth to accurately define the target area and confirm correct ozone diffusion during injection. After confirming normal skin morphology, a linear 5-needle multi-injector (30G × 4 mm) was used. Ozone was administered at a concentration of 5 μg/mL for a total volume of 10 mL, evenly distributed throughout the symptomatic area. Clinical response was assessed using the Worst Itch Numeric Rating Scale (WI-NRS). A second treatment session was performed using the same protocol after partial symptom recurrence.
Results. Following the first treatment session, the patient experienced a marked reduction in both pruritus and burning pain (WI-NRS decreased from 8 to 2–3). In the subsequent weeks, symptoms partially recurred but remained less severe than baseline levels (WI-NRS 6). After the second session, a more pronounced and sustained improvement was observed, with symptoms decreasing to WI-NRS 1. During follow-up over the following months, the patient reported stable symptom control, with maximum WI-NRS scores of 2–3, without requiring additional pharmacological or interventional therapies. The procedure was well tolerated, with only mild transient burning reported during injection and no adverse events. Ultrasound guidance allowed accurate dermal targeting and homogeneous distribution of ozone within the affected area.
Conclusions. This case report suggests that ultrasound-guided ozone mesotherapy may represent a safe and effective therapeutic option for patients with notalgia paresthetica refractory to conventional topical treatments. The clinical benefit observed may derive from both the anti-inflammatory and analgesic properties of ozone and its potential mechanical effect in reducing local nerve impingement. The use of ultrasound guidance combined with a multi-injector needle enhances procedural precision, ensures reproducible dermal diffusion, and minimizes the risk of excessively superficial or deep infiltration, regardless of patient anthropometric variability. Although limited to a single case, these findings support further investigation through larger controlled studies to better define the role of this minimally invasive approach in the management of chronic neuropathic pruritus.