The itchy patient_1_ by hilen

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									The itchy patient

   Maggie Kirkup
 SpR Dermatology
Royal United Hospital
                   Lambeth study1
• 55% population had a skin problem

• Approx 40% of these were itchy conditions

  1. Rea et al Br J Prev Soc Med 1976; 30: 107-14
       Descriptions of itching
“local discomfort or irritation of the skin,
  prompting the sufferer to scratch or rub the
  affected area. It is the main symptom of
  skin disease”

• “a peculiar tingling or uneasy irritation of
  the skin that causes a desire to scratch the
  affected area”
         Benefits of itching
• Scratching may combat ectoparasites
• Scratching can be pleasureable
“It feels as though every nerve ending in my body
is attacking me intensely at my ankles, feet, lower
legs, neck, under the breasts (even the nipples
tingle). It's absolutely horrendous! My hands grow
red as a beet and the itching nearly takes the skin
off my hands as I scratch.”

All Party Parliamentary Group on Skin. Report on the Enquiry into the
Impact of Skin Diseases on People’s Lives. 2003
• Neurological
  – Specific receptors and nerve fibres or shared
    with pain?
• Chemical mediators
  – Include histamine, opiod peptides, serotonin
• Central
  – Dysfunctional processing of sensory
Approach to diagnosis of itching
• History
  including onset, duration, effect on sleep,
  previous skin disease, contacts, other
  medical problems, drugs, response to
  treatment so far
• Skin examination
   features of rash, signs of response to
• General examination
      Signs of response to itching
•   excoriation
•   distress
•   lichenification
•   shiny nails
•   weals
•   nodules
    Factors affecting presentation of
             itchy condition
•   age
•   other medical conditions/ ability to scratch
•   site of itch
•   self-control/ social setting/ distractions
•   specific skin condition
•   duration
               Causes of itch
•   skin disorders
•   systemic disorders
•   psychogenic
•   habit    (itch-scratch cycle)
•   idiopathic / cause not yet found
•   physiological?
               Causes of itch
•   skin disorders
•   systemic disorders
•   psychogenic
•   habit
•   idiopathic
•   physiological?
    Common generalised itchy skin
•   infestations: scabies   • lichen planus
•   eczemas                 • pityriasis rosea
•   xerosis/senescence      • bullous pemphigoid
•   psoriasis               • polymorphic light
•   urticaria                 eruption
•   viral exanthems         • insect bites
•   drug eruptions
Less common skin complaints which
• dermatitis herpetiformis
• aquagenic pruritus

• some T cell lymphomas
• onchocerciasis etc etc
             Localised itch
• Scalp: lice, seborrhoeic dermatitis
• Flexures: atopic/ seborrhoeic eczema
• Hands: eczemas, scabies, contact dermatitis
• Anogenital/ pruritus ani - think of
  threadworms, lichen sclerosis, lice, contact
• Any area: discoid eczema, lichen simplex
  chronicus, contact dermatitis
Less common causes of localised

• brachioradial pruritus

• notalgia paraesthetica
      Skin disorders which don’t
             (usually) itch
•   psoriasis ?
•   acne / folliculitis
•   vasculitis/purpura
•   erythema multiforme
•   secondary syphilis
               Causes of itch
•   skin disorders
•   systemic disorders
•   psychogenic
•   habit
•   physiological?
         Systemic causes of itch
•   liver disease (cholestasis)
•   chronic renal failure
•   iron deficiency
•   hypo and hyper thyroidism
•   hypocalcaemia
•   diabetes mellitus
         Systemic causes of itch
• malignancies:
    – lymphoma, PRV, leukaemias, myeloma
•   pregnancy
•   neurological
•   drugs
    – seb derm, cholestasis, scabies, candida,
      eosinophilic folliculitis
             Psychogenic itch
•   epidemic forms - hysteria
•   delusional parasitosis
•   habit - itch/scratch cycle
•   pruritus ani
•   diagnosis by exclusion
Screening investigations in itchy
     patients with no rash
•   Full blood count
•   Ferritin
•   Renal function
•   Liver function
•   Thyroid function
•   ? Chest X ray
       Management of itching
• Treat the cause

• Treat the itch
       Management of itching
• There is no specific drug for itch
       Management of itching
• avoid provoking and aggravating factors
     temperature, humidity, bedding, clothing

• reduce damage from scratching
     clothing, bandaging, cut nails
         Management of itching
•   topical agents
•   gadgets
•   systemic agents
•   psychological interventions
•   keep looking for a cause
                Topical agents
• emollients
• antihistamines* - doxepin (Xepin)
• unknown mechanism
      crotamiton (Eurax)
• counter-irritant capsaicin, menthol
• local anaesthetics*
  * Risk   sensitization
         Management of itching
•   topical agents
•   gadgets
•   systemic agents
•   psychological interventions
The “Electronic

“This is a high-tech medical device. More than half a million of people are using
it already.
Just press Itch Stopper against the itchy sites for 5 to 20 seconds while the mild
electronic energy produced destroys trouble-causing toxins beneath the skin and
stops histamine release. In one minute, the itch is gone for up to 24 hours.
Completely safe - even for three month old babies.

Histamine is the final cause of itch, rash, inflammation, skin redness and
blistering. This product stops histamine release instantly so that the itch will be
erased in seconds. Rashes, inflammation, skin redness and blistering will go away
quickly. It has no harmful side effects.”
         Management of itching
•   topical agents
•   gadgets
•   systemic agents
•   psychological interventions
             Systemic agents
• Antihistamines
  – urticaria, dermographism, atopic eczema
• Opiod antagaonists
  – cholestasis, notalgia paraesthetica
• Ondansetron
  – cholestasis
• Cholestyramine
  – cholestasis
            Systemic agents
• Antidepressants, anxiolytics
  – some psychogenic problems
• Thalidomide
  – Nodular prurigo
• Phototherapy
  – uraemic pruritus, PRV,aquagenic pruritus
         Management of itching
•   topical agents
•   gadgets
•   systemic agents
•   psychological interventions
      Psychological and alternative
• Biofeedback
• Behavioural therapy*
• Relaxation techniques
• Acupuncture
• Hypnotherapy
• Homeopathy
• Self-help groups
*Melin I et al Behavioural treatment of scratching in patients with atopic dermatitis.
    Brit J Dermatol 1986; 115: 467-74
• Itching can be caused by skin disease,
  systemic disease, psychogenic factors or
• Management and investigation need to be
  tailored to the patient’s condition and
• Keep looking for a cause if no rash evident

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