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Generalised pruritus

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Generalised pruritus

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Pruritus (lat. prurigo ) is defined as an unpleasant sensation of skin leading
 to the desire to scratch ( itch )

Common dermatological problem Often intractable with a high impact on quality of life Increases with age
Estimated that 60 % of people > 65 suffer from mild to severe occasional pruritus each week Exact prevalence is not known Can be caused by both skin and systemic problems International forum for the study of Itch has suggested a classification which considers clinical as well as differential diagnostic reasons

Systemic causes- Metabolic and Endocrine
♦ Chronic renal insufficiency
♦ hyperparathyroidism
♦ hyper & hypothyroidism
♦ Carcinoid syndrome
♦ Diabetes
 Hepatic
♦ PBC
♦ Extrahepatic biliary obstruction
♦ Cholestasis of pregnancy
♦ Hepatitis
♦ Oral contraceptives
♦ Drug ingestion
 Infective disease
♦ HIV and AIDS
♦ Parasitoses including Helminthosis
 Haematological
♦ Polycythemia vera
♦ Myelodisplastic syndrome
♦ Lymphoma eg Hodgkins lymphoma
♦ Multiple myeloma
♦ Iron deficiency
 Neurological disorders
♦ Multiple sclerosis
♦ Brain tumours ( eg gliomas )
♦ Notalgia paraesthetica
♦ Brachioradial pruritus
♦ Peripheral neuropathy
 Psychiatric or Psychosomatic diseases
♦ Depression
♦ Affective disorders
♦ Hallucinosis
♦ OCD
♦ Schizophrenia
♦ Eating disorders


Dermatological causes-Xerosis Scabies Dermatitis herpetiformis Atopic dermatitis Lichen simplex Psoriasis Lichen planus Contact dermatitis Miliaria Drug reactions Insect bites Pruritic urticarial papules and plaques of pregnancy Peduculosis Urticaria Folliculitis Sunburn Polymorphous light eruption Bullous pemphigoid Pemphigus foliaceus Pityriasis rosea Fiberglass dermatitis Fungal infections Mycosis fungoides Seborrhoeic dermatitis

history-Onset , duration Intensity Timing Itch characteristic for eg
prickling
crawling
burning Rash ? Site eg
entire skin
palpebral conjunctiva
perianal / perogenital
ear canals , eyelids, nostrils Associated symptoms Disturbing sleep ? Relieving factors Medical history Drug history , cosmetics , creams ? Blood transfusions Others itching ? ( scabies ) Alcohol abuse , sexual hx , drug abuse Dietary history



Examination Assess severity for eg using an visual analogue score ( VAS ) Skin examination Mucous membranes Scalp Hair Nails Anogenital region Distribution of primary and secondary skin lesions Skin signs of systemic disease Palpation of liver , kidneys , spleen and lymph nodes Mental state – psychological impact

Testing- Renal function FBC , ESR LFTs , Bone profile , Vit D , Bl glucose , HbA1c TFTs Iron studies Blood morphology , LDH ANA HIV and hepatitis A, B and C serology Electrophoresis IgE serum levels ( total and sllergen specific ) Stool test for ova , parasites or blood Prick tests with specific allergens Microscopy of skin scrapings Dermoscopy Skin biopsy CXR CT scan of neck , thorax , abdomen and pelvis MRI of brain and spinal cord Red flags-Bullous pemphigoid Hodgkins lymphoma Polycythemia vera HIV Infection / AIDS Paraneoplastic pruritis Brain tumour Stroke

management- Where possible manage underlying cause Discontinue drugs where possible Emollients with active ingredients for eg Menthol 0.5 % or 1 % , phenol
or camphor Treat skin infections Topical therapy Capsaican particularly renal ( poor pt compliance ) , topical doxepin , crotamion cream Systemic therapy ( seek adv from dermatology where appropriate )
♦ sedating anti-histamines eg hydroxyzine ( Atarax ) 10-25 mg nocte
♦ Non sedating anti histamines eg Fexofenadine 180 mg
♦ Anti-depressants eg Tricyclics ( amitriptyline , doxepin ) , SSRIs
 ( paroxetine ) , Mirtazepine @ 15 mg
♦ Anti-convulsants and pain modulators – eg gabapentin or pregabalin
♦ Opioid receptor antagonists ; agonists eg Naltrexone
♦ Rifampicin ( hepatic pruritus ) , Cholestyramine
♦ Ondansetron , NSAIDs , H1 and H2 antagonists in combination for eg fexofenadine and cimetidine UV phototherapy Psychosomatic therapy

References European Dermatology Forum Update of the guideline on Chronic Pruritus accessed via www.medicaljournals.se BMJ Best Practice Assessment of pruritus Pruritis : causes and management July 2006 / midlife and beyond/ geriatric medicine Pruritis Scott Moses MD AFP Sept , 2003 / Volume 68 , Number 6 Management of itching Abhishek Sharma et al JIACM 2009 ; 10 (3) : 119-27 Chronic Pruritus ; Clinics and Treatment Sonja Grundmann , MD et al Department of Dermatology , Neurodermatology and Competence Center Chronic Priritus , University Hospital Munster , Munster , Germany Itch widespread CKS NHS Nov 2015 Chronic Pruritus in the Geriatric Population Dermatolgic Clinics Cao , Taige , MD et al Understanding Pruritus in Systemic Disease Journal of Pain and Symptom Management Vol . 21 No 2 February 2001 British Association of Dermatologists Guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018 British journal

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