Generalized Pruritus

Background:Generalized pruritus can often be the primary manifestation of systemic disease. Objective:To determine how frequently generalized pruritus had a systemic etiology in an outpatient population seen in a dermatology department and whether any identifiable patient characteristics meant a systemic explanation of generalized pruritus was more likely. Methods:A prospective controlled study of 55 patients with generalized pruritus and 41 healthy age- and sex-matched control subjects. Clinical data were collected from patients and laboratory parameters investigated in both patients and healthy control subjects to determine the frequency of systemic disease in each group. Results: Of 55 patients, 12 had a systemic cause of pruritus. Pruritus was the initial symptom of systemic disease in eight of these patients. The underlying diseases included hypothyroidism, chronic lymphocytic leukemia, hepatitis C, hepatitis B, diabetes mellitus, lung cancer, uremia, and iron deficiency anemia. Of these, iron deficiency anemia was the most common cause. Compared with the control group, mean serum hemoglobin, iron, and cyanocobalamin (vitamin B₁₂) levels in patients with generalized pruritus were lower. No other patient characteristics were statistically associated with systemic causes of pruritus. Conclusion:Generalized pruritus was the initial symptom of a systemic disease in 8 of 55 patients presenting to a dermatology outpatient clinic with this complaint. A number of underlying diseases were identified, of which the most common was iron deficiency anemia.     

Intractable chronic pruritus in a 67-year-old man

Chronic pruritus (> 6 weeks) can be caused by skin diseases and systemic diseases, including malignancies. It is a distressing symptom that requires a precise medical history, thorough physical examination, laboratory and radiological diagnostics. The interpretation of results may sometimes be difficult and may often reveal several patho notlogical findings. This case report demonstrates prostate cancer as a possible underlying disease in a patient with chronic pruritus. Therapy with the selective serotonin reuptake inhibitor paroxetine significantly relieved pruritus, but was less effective when external therapy was discontinued. Most pruritus patients need conse notcutive or combined aetiological and symptomatic (topical and systemic) therapy.     

Pruritus of unknown origin: A retrospective study

BACKGROUND: Pruritus of unknown origin is a common complaint, and systemic causes must be considered. However, there is little data on how frequently systemic causes are responsible or whether any patient characteristics make a systemic cause more likely. OBJECTIVE: We attempted to determine how frequently pruritus of unknown origin had a systemic etiology in an outpatient population seen in a university dermatology department and whether any patient characteristics made a systemic explanation more likely. METHODS: This is a retrospective study using chart reviews and telephone interviews to collect data. RESULTS: Of 50 patients, 11 had a systemic cause of pruritus. Pruritus was the initial symptom of systemic disease in 7 of these patients. No patient characteristics were statistically associated with systemic causes of pruritus. CONCLUSION: Pruritus of unknown origin was the initial symptom of a systemic disease in 7 of 50 patients presenting to a dermatology clinic with this complaint. The underlying diseases included hypothyroidism, gastric adenocarcinoma, hepatitis C, HIV, laryngeal carcinoma, graft-versus-host disease, and chronic lymphocytic leukemia.     

Current and Emerging Therapies for Itch Management in Psoriasis

Pruritus is a common and significant symptom among patients with psoriasis. Pruritus is often present beyond the borders of psoriatic plaques, and frequently affects the scalp and genital regions. Psoriatic itch may be severe and can profoundly affect quality of life and sleep, even in the context of mild-to-moderate disease. These features often make the treatment of psoriatic pruritus challenging. However, there are a variety of effective topical and systemic treatment modalities available to address this symptom. While there remains a need for treatments that specifically target psoriatic itch, newly licensed therapies including secukinumab, ixekizumab and apremilast have been shown to rapidly and effectively mediate itch reduction.     

How to define chronic pruritus: Symptom or disease?

Chronic pruritus (CP) is defined by itching lasting 6 weeks or more and is known to be both a highly prevalent and burdensome symptom of many pruritogenic diseases. Its status as a symptom has many implications mainly that the symptom should evolve and subside with the disease. However, according to the clinical experience, CP often does not parallel the disease course and requires an own management. It is speculated that neuronal sensitization processes take place, which lead to disconnection of the symptom from the underlying disease and establishment of an own course of pruritus. It is thus discussed that pruritus can be both a symptom of diseases and an entity by itself. Further studies are needed to learn more and improve our understanding of this condition. This article compares its role in pruritogenic diseases, encourages discussion on the topic and provides an overview of the proper questions to ask.     

Pruritus bei inneren Erkrankungen

Chronic itch is a frequent symptom not only associated with skin diseases. In a number of internal, neurological and psychiatric illnesses pruritus can be a prominent and distressing symptom. Diagnosis is frequently very cumbersome because pruritus in these diseases often does not cause any specific skin lesions. This report focuses on the most important internal disease entities causing pruritus and highlights the most successful diagnostic and therapeutic approaches.     

Pruritus in the elderly

Pruritus is an unpleasant sensation leading to the desire to scratch. It is the most common symptom in dermatology, and various skin and systemic diseases can be associated with the presence of itching. Pruritus may also be provoked by numerous drugs. Although the exact epidemiologic data are still absent, it is generally accepted that elderly people frequently suffer from pruritus, and the problem of itching in this population remains a challenge for clinicians. The elderly often complain of numerous comorbidities that complicate the determination of the cause of pruritus, as well as its treatment. Physical and mental deprivation may complicate proper assessment of pruritus severity and negatively impair compliance with complex antipruritic therapies. Taking also into account heterogeneity of possible causes of pruritus, every patient with pruritus must be handled individually, regarding the diagnostic procedures and antipruritic therapy.     

Pruritus as a leading symptom: clinical characteristics and quality of life in German and Ugandan patients

BACKGROUND: Pruritus is the most frequent and distressing symptom associated with dermatoses and various internal and neurological diseases. OBJECTIVES: To investigate two different populations of patients with pruritus, one in Germany and one in Uganda, with a particular focus on clinical characteristics, aetiology and quality of life. METHODS: We investigated by questionnaire 132 patients (59 men, 73 women, mean age 54.5 years) who were referred to the Department of Dermatology at the University Hospital of Magdeburg, Germany, with the diagnosis of pruritus as a leading symptom. The questionnaire was also applied in 84 patients who consulted the Dermatology Clinic at Mbarara, Uganda for pruritus. The questions referred to personal data and disease history of the individual, history and present occurrence of concomitant diseases, present and past therapy, quality, frequency and triggers of itching and scratching, other disorders and complaints, quality of life and impact on work and disability. RESULTS: Seventy-five (57%) of the German patients had pruritus due to dermatoses, 47 patients (36%) had pruritus due to a systemic disease and in 10 patients (8%) pruritus was of unknown origin. Most had a history of pruritus of several months up to years. Pruritus associated with dermatoses mostly affected the whole body and was permanent with an undulatory character. Affective reactions such as aggression and depression occurred more frequently in dermatological patients compared with those with systemic pruritus. The former group felt that pruritus had a greater impact on their lives. Almost all Ugandan patients had pruritus due to dermatoses except for three patients with pruritus of unknown origin. Eczema and prurigo were the most frequently observed dermatoses in both German and Ugandan patients. Patients with pruritus in both populations showed an impaired quality of life. There was no pronounced difference between the populations with regard to feelings of depression and suicidal thoughts. CONCLUSIONS: A great deal of helpful information in this complex group of patients can be obtained using this questionnaire. Pruritus has a major impact on quality of life and especially impairs those patients with pruritus associated with dermatoses and pruritus of unknown origin.     

[Translated article] Pruritus in Dermatology: Part 1—General Concepts and Pruritogens

Pruritus is the most common symptom of dermatologic and systemic diseases. The diagnosis of pruritus is clinical, although additional tests may be necessary to identify or confirm the cause. Translational medicine has led to the discovery of new mediators of itch, or pruritogens, as well as new receptors. Knowing how to properly recognize the main pathway that mediates itch in each patient is the key to successful treatment. Although the histaminergic pathway predominates in conditions like urticaria or drug-induced pruritus, it is the nonhistaminergic pathway that predominates in nearly all other skin diseases covered in this review. Part 1 of this 2-part review discusses the classification of pruritus, additional testing, the pathophysiology of itch and the pruritogens implicated (including cytokines and other molecules), and central sensitization to itch.     

Prurito en dermatología. Generalidades y pruritógenos. Parte 1

Pruritus is the most common symptom of dermatologic and systemic diseases. The diagnosis of pruritus is clinical, although additional tests may be necessary to identify or confirm the cause. Translational medicine has led to the discovery of new mediators of itch, or pruritogens, as well as new receptors. Knowing how to properly recognize the main pathway that mediates itch in each patient is the key to successful treatment. Although the histaminergic pathway predominates in conditions like urticaria or drug-induced pruritus, it is the nonhistaminergic pathway that predominates in nearly all other skin diseases covered in this review. Part 1 of this 2-part review discusses the classification of pruritus, additional testing, the pathophysiology of itch and the pruritogens implicated (including cytokines and other molecules), and central sensitization to itch.     

Clinical classification of itch: a position paper of the International Forum for the Study of Itch

Chronic itch is a common and distressing symptom that arises from a variety of skin conditions and systemic diseases. Despite this, there is no clinically based classification of pruritic diseases to assist in the diagnosis and cost-effective medical care of patients with pruritus. The proposed classification focuses on clinical signs and distinguishes between diseases with and without primary or secondary skin lesions. Three groups of conditions are proposed: pruritus on diseased (inflamed) skin (group I), pruritus on non-diseased (non-inflamed) skin (group II), and pruritus presenting with severe chronic secondary scratch lesions, such as prurigo nodularis (group III). The next part classifies the underlying diseases according to different categories: dermatological diseases, systemic diseases including diseases of pregnancy and drug-induced pruritus, neurological and psychiatric diseases. In some patients more than one cause may account for pruritus (category "mixed") while in others no underlying disease can be identified (category "others"). This is the first version of a clinical classification worked out by the members of the International Forum for the Study of Itch. It is intended to serve as a diagnostic route for better evaluation of patients with chronic pruritus and aims to improve patients' care.     

Dermatitis herpetiformis Duhring

Celiac disease is a genetically determined bowel disease also influenced by exogenous factors in which exposure to grain components triggers a chronic immune response with intestinal symptoms. Dermatitis herpetiformis represents the cutaneous manifestation of celiac disease. While intense pruritus is the characteristic symptom, clinical signs can be highly variable, ranging from grouped papulovesicles with excoriations or eczema-like lesions to minimal variants of discrete erythema and digital purpura. Diagnosis depends on direct fluorescence studies of perilesional skin displaying granular IgA deposits in dermal papillae. Suspecting and then searching for dermatitis herpetiformis is often clinically challenging, as the disease is a true chameleon with many clinical faces. Dapsone therapy alleviates the cutaneous symptoms and signs, but does not prevent the systemic complications of celiac disease; thus, strict adherence to a gluten-free diet is strongly advisable.     

Dermatitis herpetiformis. A clinical chameleon

Celiac disease is a genetically determined bowel disease also influenced by exogenous factors in which exposure to grain components triggers a chronic immune response with intestinal symptoms. Dermatitis herpetiformis represents the cutaneous manifestation of celiac disease. While intense pruritus is the characteristic symptom, clinical signs can be highly variable, ranging from grouped papulovesicles with excoriations or eczema-like lesions to minimal variants of discrete erythema and digital purpura. Diagnosis depends on direct fluorescence studies of perilesional skin displaying granular IgA deposits in dermal papillae. Suspecting and then searching for dermatitis herpetiformis is often clinically challenging, as the disease is a true chameleon with many clinical faces. Dapsone therapy alleviates the cutaneous symptoms and signs, but does not prevent the systemic complications of celiac disease; thus, strict adherence to a gluten-free diet is strongly advisable.     

Chronischer Pruritus

Chronic pruritus (starting from 6 weeks duration) is symptom of dermatological, internal, neurological or psychiatric disease. Identification and treatment of the underlying diseases is of great importance especially in the initial phase of chronic pruritus in order to prevent peripheral and central sensitization processes and thus chronification. Application of the redefined clinical classification, newly defined clinical algorithms and inquiry of clinical characteristics of pruritus is helpful in finding the underlying disease. In chronic pruritus existing for several years, clarifying the underlying origin is difficult and therapies are often ineffective. Next to conventional therapies such as antihistamines and corticosteroids, central effective substances can be applied preventing pruritus sensation on spinal or cerebral level.     

Chronic pruritus: principals of diagnostics and therapy

Chronic pruritus (starting from 6 weeks duration) is symptom of dermatological, internal, neurological or psychiatric disease. Identification and treatment of the underlying diseases is of great importance especially in the initial phase of chronic pruritus in order to prevent peripheral and central sensitization processes and thus chronification. Application of the redefined clinical classification, newly defined clinical algorithms and inquiry of clinical characteristics of pruritus is helpful in finding the underlying disease. In chronic pruritus existing for several years, clarifying the underlying origin is difficult and therapies are often ineffective. Next to conventional therapies such as antihistamines and corticosteroids, central effective substances can be applied preventing pruritus sensation on spinal or cerebral level.     

Systemic drugs with antipruritic potency

Despite the predominance of itch as a leading and distressing symptom in most of the dermatological and several systemic diseases, there is relatively little progress in understanding its pathophysiology. This is most likely the main reason for the limited number of satisfactory anti-itch treatments and the fact that even today various therapies have empirical but not evidence-based character. There are no specific antipruritic drugs on the market, but there are a high number of case reports and experimental investigations describing medications with antipruritic potency. It is therefore the aim of this article to briefly review the major systemic antipruritic drugs and give a short overview on the different types of pruritus and their possible systemic therapy.     

Chronic generalized pruritus without primary skin lesions: a longitudinal prospective observational study

Pruritus is among the most common complaints in the field of dermatology. It is also a disturbing symptom of many systemic disorders. Chronic pruritus (CP) refers to the cases of the symptom which last longer than 6 weeks. We conducted a prospective analysis of patients with generalized pruritus without primary skin lesions. All patients underwent primary evaluations and then were followed from 12 to 18 months for further evaluations. Of the 5,127 patients referred to our dermatology clinic, 49 patients with generalized pruritus without primary skin lesions were evaluated. Most of the patients (44%) were in the age group of 40–60 years and female (58%). The duration of pruritus was 37.04 ± 30.4 weeks. Fifty percent of the patients with generalized pruritus had a systemic cause of pruritus. The most common underlying diseases were thyroid disorders (16.67%), diabetes mellitus (12.5%), and malignancy (8.33%). There were no significant statistical differences among the patients in terms of their age, gender, and disease duration with the underlying diseases (P = 0.47, P = 0.99, P = 0.816, respectively). However, the average age of the onset of pruritus was 12 years earlier in the women regardless of the underlying diseases (P = 0.011). Based on the findings of the study, we recommend considering endocrine disorders and malignancies as the most common underlying diseases leading to chronic pruritus without primary skin lesions.     

系统性疾病与皮肤瘙痒症的研究进展

瘙痒是常见的皮肤自觉症状,10％～ 50％的成年人均有不同程度的顽固性瘙痒,极大地影响患者心身健康.皮肤瘙痒症可分为原发性瘙痒症以及由不同系统性疾病引起的继发性皮肤瘙痒症,如肾功能不全、胆汁淤积症、血液性疾病、恶性肿瘤以及某些特殊感染等.有学者认为,瘙痒是机体某些系统性疾病的早期临床表现之一,可作为诊断系统性疾病的早期线索.     

Case for diagnosis

Acquired perforating dermatosis is a rare condition often associated with some systemic diseases, especially diabetic patients with chronic renal failure undergoing dialysis. The main symptom is pruritus and it is clinically characterized by the presence of redish-brown papular lesions in the trunk, head and neck. Biopsy of the lesion reveals epidermal invagination with keratotic plug. The etiology is poorly understood and several therapeutic measures have been disappointing.     

Cholestatic pruritus: a knowledge update

This review is focused on updating knowledge about cholestatic pruritus. It summarizes clinical-epidemiological characteristics, pathophysiology, diagnostic approach, and evidence-based therapeutic recommendations regarding this form of pruritus. Pruritus is a frequent symptom that accompanies several liver diseases, particularly cholestatic ones. The symptom may be mild and tolerable, but it can also dramatically reduce the quality of life. Although the exact pathophysiology of this form of pruritus remains unclear, current evidence supports a mixed origin. It is extremely important for dermatologists to have knowledge about cholestatic pruritus since they are usually the first physicians to be sought by the patient when they experience the symptom. In the absence of specific dermatological alterations, cholestasis must always be considered as a possible cause of pruritus. In addition to allowing an adequate diagnosis, a better pathophysiological understanding of hepatic pruritus provides the identification of new therapeutic targets and, consequently, optimization of the approach in patients with this condition.