itch in medicine

PruritusPagina 1 di 10 1. About Us 2. myCME Login 3. Contact Us 4. FAQ 5. Monthly CME eNewsletter 6. Text Size: 7. A 8. A 9. A All documents   • • • • • • • • http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/dermatology/pru ... 12/14/2011 . Taylor Matthew J. 2010 • Related CME cases ◦ Disease Management Project Clinical Decisions Pruritus James S. It is a characteristic feature of many skin diseases and an unusual sign of some systemic diseases. 12/14/2011 ..com/medicalpubs/diseasemanagement/dermatology/pru .clevelandclinicmeded. Zirwas Apra Sood           0 Definition and etiology Pruritus or itch is defined as an unpleasant sensation of the skin that provokes the urge to scratch.Pruritus Pagina 2 di 10 • SECTION INDEX ◦ Allergy & Immunology ◦ Cardiology ◦ Dermatology ◦ Endocrinology ◦ Gastroenterology ◦ Hematology & Oncology ◦ Hepatology ◦ Infectious Disease ◦ Nephrology ◦ Neurology ◦ Preventive Medicine ◦ Psychiatry & Psychology ◦ Pulmonary Disease ◦ Rheumatology ◦ Women's Health • DISEASE MANAGEMENT PROJECT MAIN ◦ Chapter Index ◦ Editorial Board ◦ Editorial Policy • Published: August 1. 2 Pruritus may be localized or generalized and can http://www.1. com/medicalpubs/diseasemanagement/dermatology/pru . Others act independently.clevelandclinicmeded. thermal and electrical stimuli such as transcutaneous or direct nerve stimulation. risk factors. Opioids have a central pruritic action and also act peripherally by augmenting histamine itch. as well as a diagnostic and therapeutic challenge. and natural history exist for only a few specific disorders associated with itching and are mentioned in the discussion of those conditions.3 Some. act by releasing histamine from mast cells.2 Itching can be intractable and incapacitating. the levels of histamine are sufficient for a sensory but not a vascular response. Itching is an important component of some disorders (atopic eczema. vibration. The sensation is received by free nerve endings in the skin and transmitted via unmyelinated C fibers and myelinated Aδ fibers to the central spinothalamic tracts. lichen simplex chronicus. and natural history Prevalence estimates. In conditions such as mild urticaria or aquagenic pruritus. dermatitis herpetiformis.9 Box 1: Select Dermatologic Disorders Associated with Chronic Pruritus* Autoimmune • • • • Dermatitis herpetiformis Dermatomyositis Pemphigoid Sjögren's syndrome http://www. Bullous pemphigoid can manifest with a prebullous pruritic phase for several months before the characteristic blisters appear. Itching lasting more than 6 weeks is termed chronic pruritus. 4 Chemical Mediators Histamine is one of the most important mediators of itch. A characteristic rash usually establishes the diagnosis of a primary dermatologic disorder. and nodular prurigo) and these conditions are rarely diagnosed in its absence.Pruritus Pagina 3 di 10 occur as an acute or chronic condition. such as neuropeptides.3. some are listed in Box 1. Back to Top Pathophysiology Peripheral Mechanisms Physical Stimuli and Neural Pathways Itch can be produced by mechanical (gentle touch. Etiology Itching is associated with dermatologic and systemic causes. Several skin diseases are associated with pruritus. 1..8 An invisible form of mycosis fungoides can occur as pruritus without a rash and is diagnosed on biopsy. pressure. risk factors. and itching caused by them responds to antihistamines. 5-7 Administration of opioids in epidural anesthesia can also lead to pruritus. and wool). 2 Microneurography studies have demonstrated that itch and pain are transmitted by separate neural pathways. Central Mechanism Patients with tumors and lesions of the central nervous system have been reported to have intractable pruritus. 12/14/2011 . Back to Top Prevalence.1. and it is important to determine whether there is an associated skin eruption. and there may be no skin findings. although other chemical substances have also been implicated.. therefore antihistamines are not effective in some forms of pruritus. . et al: Invisible mycosis fungoides: A diagnostic challenge. 12/14/2011 .47:S167-S171. Gallardo F.Pruritus Pagina 4 di 10 Genetic • • • • Darier's disease Hailey-Hailey disease Ichthyoses Sjögren-Larsson syndrome Infections and Infestations • • • • • • • • Arthropod reactions Dermatophytosis Folliculitis Impetigo and other bacterial infections Insect bites Pediculosis Scabies Viral Inflammatory • • • • • • • • • • • • Asteatosis (dry skin). et al: Clinical Classification of itch: A position paper of the International Forum for the Study of Itch. including aging and senile pruritus Atopic eczema Contact dermatitis (irritant. dryness.. and a specific rash is not present. Weisshaar E. http://www. Select systemic conditions associated with itching are listed in Box 2. it may be the only manifesting symptom. eczematization. Llistosella E. lichenification. J Am Acad Dermatol 2002.com/medicalpubs/diseasemanagement/dermatology/pru . These findings should not be interpreted as the primary skin disorder. Pruritus of systemic disease is usually generalized. Excessive bathing and contact allergy to topical therapies can lead to dermatitis.clevelandclinicmeded. Mettang T. and Ständer S. Neurologic and psychiatric conditions associated with chronic pruritus are included in Box 2. and it can be dangerous to label a case of generalized pruritus “nonspecific eczema” until these conditions are excluded. It is important to establish if pruritus preceded the appearance of a skin eruption. Acta Derm Venereol 2007:87 291294. allergic) Drug reactions “Invisible dermatoses” Lichen planus Lichen simplex chronicus Mastocytosis (urticaria pigmentosa) Miliaria Psoriasis Scars Urticaria Neoplastic • Cutaneous T-cell lymphoma or mycosis fungoides (especially Sézary syndrome) • Cutaneous B-cell lymphoma • Leukemia cutis Pregnancy • Pemphigoid gestationis • Polymorphic eruption of pregnancy • Prurigo gestationis * Generalized or localized depending on extent of disease Adapted from Pujol RM. and infection. Several are potentially serious. Severe itching leads to scratching that causes secondary skin changes of excoriation. com/medicalpubs/diseasemanagement/dermatology/pru . 2. 3. Abscess Infarcts Multiple sclerosis Nostalgia paresthetica Tumors Anxiety disorders Depression Obsessive-compulsive disorder • Psychiatric disease http://www. 3. 2. 1. may be localized to scalp) Hyperthyroidism Hypothyroidism Liver disease (with or without cholestasis) Malabsorption Perimenopausal pruritus Infectious Diseases • Helminthosis • HIV infection • Parasitosis Neoplastic and hematological • • • • • • • Hodgkin's disease Iron deficiency Leukemia Non-Hodgkin's lymphoma Multiple myeloma Plasmacytoma Polycythemia rubra vera Visceral Neoplasms • Carcinoid syndrome • Solid tumors of the cervix. 5. 12/14/2011 . or colon Pregnancy • Pruritus gravidarum (with or without cholestasis) Drugs • • • • • • • • Allopurinol Amiodarone Angiotensin-converting enzyme inhibitors Estrogen Hydrochlorothiazide Hydroxyethyl cellulose Opioids Simvastatin Other • Neurologic disease 1. 4..clevelandclinicmeded.Pruritus Pagina 5 di 10 Box 2: Select Systemic Causes of Chronic Pruritus Endocrine and Metabolic Diseases • • • • • • • Chronic renal failure Diabetes mellitus (questionable. prostate.. . Mettang T.. J Am Acad Dermatol 2002. chills. A complete physical examination to look for other cutaneous signs mentioned in the “Review of Systems” section is essential. further testing may be indicated (Box 3). and lichenified plaques) can lead to secondary changes that should not be interpreted as a primary skin disorder but can mimic one. 12/14/2011 . color changes). loss). sweating. eyes (exophthalmos. neurologic.com/medicalpubs/diseasemanagement/dermatology/pru . plethora. Back to Top Diagnosis History A detailed history is the single most important step toward diagnosing the cause of itching. and Ständer S. Look for evidence of parasitic infestation. and genitalia with surveillance scrapings can identify either disorder. texture. genitourinary. In general. extent (generalized vs. onycholysis. diurnal and seasonal variations. localized). If the patient has recently undergone surgery. weight loss). Examination of the skin. Review of Systems A detailed history is important in chronic pruritus of unknown origin. including general health (fever.5-7. asthma). and spleen is important. complete metabolic panel. et al: Invisible mycosis fungoides: A diagnostic challenge. hematopoietic. because it is relatively inaccessible and unavailable for scratching. Scratching (causing excoriations) or rubbing (producing papules. and chest x-ray. especially scabies and lice. the diagnosis is apparent from the history. creatinine http://www. medication history and allergies. laboratory studies may be indicated. bathing. Examination of the upper midback can help in this distinction. physical examination. Llistosella E. skin (pigmentation. household and other contacts. When the diagnosis is not apparent. type of itch. hair.clevelandclinicmeded. because this substance can be associated with intense generalized pruritus lasting for up to one year. a reasonable initial screen consists of complete blood count. pets.Pruritus Pagina 6 di 10 Adapted from Pujol RM. occupation. or bedside studies (such as a scabies preparation). severity. asteatosis. travel history. nodules. allergic rhinitis. gastrointestinal. hepatitis C antibodies. liver. et al: Clinical Classification of itch: A position paper of the International Forum for the Study of Itch. sexual history. Weisshaar E. nails (Beau's lines. and endocrine. This should include information on the onset. color changes). and history of intravenous drug use (human immunodeficiency virus [HIV] or hepatitis C infection).47:S167-S171. the laboratory investigation should be directed by the findings of the history and physical examination. aggravating and alleviating factors. Based on the initial results and the course of the pruritus. In a patient with no pertinent findings. TSH. Acta Derm Venereol 2007:87 291294. and past medical and surgical history. Box 3: Laboratory Investigations for Generalized Pruritus Initial Screening Studies • Complete blood count with differential • Blood urea nitrogen. Examination of clothing seams can identify body lice in the unkempt (vagabond's disease). Inquire about personal or family history of atopy (childhood eczema. 10 Investigations In some cases. hair (growth. and jaundice). hobbies. and mental status. Gallardo F.5-7. 10 Physical Examination The skin should be examined for evidence of any recognizable disorder. Pelvic and rectal examination as well as examination of the lymph nodes. ask if hydroxyethyl cellulose was used as a plasma expander. . Cooling lotions with calamine. 12/14/2011 . Adapted from Kantor GR.14:290-296. and parasites Upper and/or lower endoscopy * To be considered based on history and physical examination. pramoxine. Histopathologic examination of the skin lesions may be required. bilibrubin Hepatitis C antibodies Thyroid-stimulating hormone Chest x-ray Other Studies* • Allergy panel 1. because an underlying disorder can manifest later. 2.. results of initial laboratory screening. or menthol and camphor are helpful (Box 4). 4. a cool environment in the home and workplace also helps.com/medicalpubs/diseasemanagement/dermatology/pru . a biopsy specimen for direct immunofluorescence from normal-appearing skin might show immune deposits in early cases of pemphigoid or findings diagnostic of mycosis fungoides in routine histopathology. immunoglobulin E. In pruritus without a rash. Symptomatic treatment should be prescribed while the primary condition is being treated. Patients with chronic idiopathic pruritus should be followed with periodic re-evaluation if the symptoms persist. and pruritus. Histamine Mast cell metabolites Serotonin Total IgE Urine 5-HIAA • • • • • • • • • • • • • • • Antinuclear antibody Antimitochondrial antibodies Antitissue transglutaminase antibodies Calcium and phosphate levels Erythrocyte sedimentation rate Fasting glucose. 5. 1995. alanine aminotransferase.clevelandclinicmeded. 10 Back to Top Treatment General Concepts and Topical and Systemic Treatments Identifying and treating the underlying cause is the most effective therapy for pruritus. hemoglobin A1C HIV screen Pan–computed tomography scan Prick testing. 5-hydroxyindoleacetic acid. Cool compresses and cool baths might help relieve the itch. alkaline phosphatase. Bernhard J: Investigation of the pruritic patient in daily practice.Pruritus Pagina 7 di 10 • • • • Aspartate transaminase. Box 4: Outline for Selected Treatments for Pruritus Topical • • • • • Anesthetics Antipruritics Cooling agents Corticosteroids Emollients http://www. 5-HIAA. IgE. patch testing Serum and urine immunofixation Serum and urine protein electrophoresis Serum iron and ferritin Skin biopsy with immunofluorescence Stool for occult blood. ova. Semin Dermatol.5-7. 3. 12/14/2011 . Semin Dermatol 1995. and selective serotonin reuptake inhibitors (SSRIs) may be considered in select patients.1. H1-receptor antihistamines are the drugs of choice for urticaria. 1. Topical tacrolimus may be prescribed for limited use in patients with atopic dermatitis.14:320-325. Patients should avoid frequent and hot baths and excessive use of soap.com/medicalpubs/diseasemanagement/dermatology/pru . 10 Treatment of Specific Disorders Chronic Renal Disease Other than general treatments as mentioned earlier. Topical capsaicin may be useful in chronic localized pruritus such as notalgia paresthetica. cholestyramine. Third-line therapies include thalidomide and parathyroidectomy. as well as correcting the temperature and humidity. 10 Dialysis can provide some relief but rarely improves itching significantly. probably act by lowering levels of bile salts and other pruritogens. Pruritus due to dry skin. Parathyroid hormone levels have been found to be increased and have been implicated as a cause. Altered central opioidergic neurotransmission is believed to be a contributing factor.clevelandclinicmeded.6 Renal transplantation is the definitive treatment. such as naloxone. and the opioid antagonist naltrexone. especially in the elderly. Aggressive treatment of the eczema may be the only way to control the pruritus in patients with atopic dermatitis. have occasionally been used for intractable pruritus of renal and cholestatic diseases. which further dries the skin. 10 Cholestatic Disease Ion-exchange resins. severe pruritus. Other measures that have been tried for chronic pruritus are acupuncture and transcutaneous electrical nerve stimulation (TENS) (see Box 4). Limited use of systemic corticosteroids as well as other systemic immunosuppressives may be needed to treat the eczema.. buspirone.Pruritus Pagina 8 di 10 Systemic • Antihistamines • Corticosteroids • Opioid-receptor antagonist Phototherapy • Ultraviolet B. the older sedating antihistamines might work better.. mild disease might respond to UVB phototherapy and erythropoietin. Ultraviolet (UV) B phototherapy is very effective in uremic pruritus and may be helpful in patients with prurigo nodularis. Wahlgren C: Treatment of itch.1. and aquagenic pruritus. 12 and opioid antagonists such as naloxone and naltrexone have been found useful. HIV infection. These patients experience relief of pruritus after parathyroidectomy. Second-line treatments include oral activated charcoal. Gabapentin. broad band or narrow band • Ultraviolet A1 Miscellaneous • Acupuncture • Capsaicin • Transcutaneous electrical stimulation Adapted from Hagermark O. responds to generous amounts of emollients such as petrolatum and white paraffin. The newer nonsedating antihistamines are less effective in atopic dermatitis. such as cholestyramine. atopic dermatitis. which has been shown to reduce pruritus in http://www. Topical corticosteroids should not be prescribed indiscriminately but should be used only if there are signs of cutaneous inflammation. Tricyclic antidepressants such as doxepin have antihistamine activity in addition to central effects and are useful in chronic. Opioid-receptor antagonists.13 Second-line therapies include rifampicin. pp 85-94. Pruritus in skin disease. Int J Dermatol. Heymann WR. St Louis: Mosby Elsevier. Back to Top http://www. et al: Invisible mycosis fungoides: A diagnostic challenge.1. 14 ursodeoxycholic acid. 1995. extracorporeal albumin dialysis. 3. 2nd ed. 47: S167-S171. Zirwas MJ. The presence of skin changes does not exclude the possibility of an underlying systemic cause of the pruritus. 4. 37: 507-514. a cannabinoid. Itch: Mechanisms and Management of Pruritus. Hagermark O. Wahlgren C. Third-line treatment includes UVB phototherapy. 7. In: Bolognia JL. 14: 290-296. 12/14/2011 . Oursler JR. 2003. Gallardo F. Ständer S. Steinhoff M. 1. 1994. Semin Dermatol. Rapini RP (eds): Dermatology. 6. Seraly MP. Schmelz M. The absence of a rash does not automatically mean that the underlying cause of the itching is a systemic disease. 10 Back to Top Summary • • • • Pruritus or itch is a characteristic feature of many skin diseases and an unusual sign of some systemic diseases. Greaves M. Investigation of the pruritic patient in daily practice.clevelandclinicmeded.. 2006. • Identifying and treating the underlying cause are the most effective therapies for pruritus. New York: McGraw-Hill. Semin Dermatol. skin biopsy. but psoralen plus ultraviolet A (PUVA) phototherapy has been helpful in some patients. 45: 892-896. Pujol RM. 1998. Weisshaar E. 2007. Ständer S. Llistosella E. Acta Derm Venereol. Mettang T. Bernhard J. pp 37-67. and a trial showed SSRIs to be effective. 1995. Jorizzo JL.. J Am Acad Dermatol. Back to Top References 1.com/medicalpubs/diseasemanagement/dermatology/pru . 2002. et al: Neurophysiology of pruritus: Cutaneous elicitation of itch. and S-adenosylmethionine. and radiographic studies as dictated by history and physical findings. Pruritus of unknown origin: A retrospective study. and dronabinol. Berth-Jones J. In: Lebwohl M. SSRIs. 139: 1463-1470.Pruritus Pagina 9 di 10 patients with primary biliary cirrhosis. plasmapheresis. Aspirin has been reported effective. Bernhard JD. Bernhard JD(ed:) . 87: 291-294. Coulson I (eds): Treatment of Skin Disease. 2001. Rogers RS III. pp 533-537. 2003. including laboratory tests. 2. et al: Clinical Classification of itch: A position paper of the International Forum for the Study of Itch. St Louis: Mosby. Dermatologic and internal medicine evaluations. Bullous pemphigoid presenting as generalized pruritus: Observation in six patients. 10 Polycythemia Rubra Vera Antihistamines are usually ineffective. 8. J Am Acad Dermatol. Kantor GR. Treatment of itch. 14: 320-325. Mediators of pruritus. Pruritus. 9. Alonso-Llamazares J. should be considered for patients with generalized pruritus lasting longer than 6 weeks. Arch Dermatol. Bernhard JD. 10. 5. Ward JR. Calobrisi SD. Pruritus. 12/14/2011 . Jorizzo JL. Gallardo F. Steinhoff M. 14: 320-325. Cleveland. 2003. St Louis: Mosby Elsevier. J Am Acad Dermatol. pp 533-537. Mettang T. Llistosella E. Seraly MP. Center for Continuing Education | 9500 Euclid Avenue.clevelandclinicmeded. Treatment of itch. • Hagermark O. Weisshaar E. Cleveland.. All Rights Reserved. KK31. Bullous pemphigoid presenting as generalized pruritus: Observation in six patients. • Zirwas MJ. 2nd ed. Calobrisi SD. 37: 507-514. • Bernhard JD. Center for Continuing Education | 9500 Euclid Avenue.Pruritus Pagina 10 di 10 Suggested Readings • Alonso-Llamazares J. • Ständer S.com/medicalpubs/diseasemanagement/dermatology/pru . 45: 892-896. • Ständer S. 2002. OH 44195 • • • • • • • Main Cleveland Clinic Website Accreditation with Commendation Awards Site Disclaimer Privacy Policy Feedback Sitemap Copyright © 2000-2011 The Cleveland Clinic Foundation. 14: 290-296. Wahlgren C. J Am Acad Dermatol. 87: 291-294. Coulson I (eds): Treatment of Skin Disease. • Ward JR. 2007. St Louis: Mosby. et al: Clinical Classification of itch: A position paper of the International Forum for the Study of Itch. Semin Dermatol. 139: 1463-1470.. Arch Dermatol. Berth-Jones J. In: Bolognia JL. Heymann WR. 1995.   • Editorial Policy • Disease Management Project Disclaimer Copyright © 2000-2011 The Cleveland Clinic Foundation. Pruritus of unknown origin: A retrospective study. Rogers RS III. New York: McGraw-Hill. 1994. Oursler JR. 1995. All Rights Reserved. 2001. OH 44195 http://www. Schmelz M. 2003. Rapini RP (eds): Dermatology. et al: Neurophysiology of pruritus: cutaneous elicitation of itch. 2006. Bernhard J. Acta Derm Venereol. Semin Dermatol. 1998. pp 85-94. 47: S167-S171. Pruritus in skin disease. et al: Invisible mycosis fungoides: A diagnostic challenge. Mediators of pruritus. pp 37-67. • Pujol RM. • Kantor GR. Investigation of the pruritic patient in daily practice. Int J Dermatol. Bernhard JD. • Greaves M. KK31. Bernhard JD: Itch: Mechanisms and Management of Pruritus. In: Lebwohl M.