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Severe itching leads to scratching that causes secondary skin changes of excoriation, lichenification, dryness, eczematization, and infection. Excessive bathing and contact allergy to topical therapies can lead to dermatitis. These findings should not be interpreted as the primary skin disorder. Select systemic conditions associated with itching are listed in Box 2. Pruritus of systemic disease is usually generalized, it may be the only manifesting symptom, and a specific rash is not present. Neurologic and psychiatric conditions associated with chronic pruritus are included in Box 2.

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A detailed history is the single most important step toward diagnosing the cause of itching. This should include information on the onset, extent generalized vs.

2016: The Itchy Patient, Why Patients Develop Pruritus

Inquire about personal or family history of atopy childhood eczema, allergic rhinitis, asthma , household and other contacts, pets, travel history, sexual history, and history of intravenous drug use human immunodeficiency virus [HIV] or hepatitis C infection. If the patient has recently undergone surgery, ask if hydroxyethyl cellulose was used as a plasma expander, because this substance can be associated with intense generalized pruritus lasting for up to one year.

A detailed history is important in chronic pruritus of unknown origin, including general health fever, chills, weight loss ; skin pigmentation, sweating, asteatosis, plethora, and jaundice ; hair growth, texture, loss ; nails Beau's lines, onycholysis, color changes ; eyes exophthalmos, color changes ; and endocrine, hematopoietic, gastrointestinal, genitourinary, neurologic, and mental status.

The skin should be examined for evidence of any recognizable disorder. Scratching causing excoriations or rubbing producing papules, nodules, and lichenified plaques can lead to secondary changes that should not be interpreted as a primary skin disorder but can mimic one. Examination of the upper midback can help in this distinction, because it is relatively inaccessible and unavailable for scratching. Look for evidence of parasitic infestation, especially scabies and lice. Examination of the skin, hair, and genitalia with surveillance scrapings can identify either disorder. Examination of clothing seams can identify body lice in the unkempt vagabond's disease.

Pelvic and rectal examination as well as examination of the lymph nodes, liver, and spleen is important. In some cases, the diagnosis is apparent from the history, physical examination, or bedside studies such as a scabies preparation. When the diagnosis is not apparent, laboratory studies may be indicated. In general, the laboratory investigation should be directed by the findings of the history and physical examination. In a patient with no pertinent findings, a reasonable initial screen consists of complete blood count, complete metabolic panel, hepatitis C antibodies, TSH, and chest x-ray.

Based on the initial results and the course of the pruritus, further testing may be indicated Box 3. Semin Dermatol. Histopathologic examination of the skin lesions may be required. In pruritus without a rash, 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.

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Patients with chronic idiopathic pruritus should be followed with periodic re-evaluation if the symptoms persist, because an underlying disorder can manifest later. Identifying and treating the underlying cause is the most effective therapy for pruritus. Symptomatic treatment should be prescribed while the primary condition is being treated. Cool compresses and cool baths might help relieve the itch; a cool environment in the home and workplace also helps.

Cooling lotions with calamine, pramoxine, or menthol and camphor are helpful Box 4. Semin Dermatol ; Pruritus due to dry skin, especially in the elderly, responds to generous amounts of emollients such as petrolatum and white paraffin, as well as correcting the temperature and humidity.

Patients should avoid frequent and hot baths and excessive use of soap, which further dries the skin. Topical corticosteroids should not be prescribed indiscriminately but should be used only if there are signs of cutaneous inflammation. Topical tacrolimus may be prescribed for limited use in patients with atopic dermatitis.

Topical capsaicin may be useful in chronic localized pruritus such as notalgia paresthetica. H 1 -receptor antihistamines are the drugs of choice for urticaria. The newer nonsedating antihistamines are less effective in atopic dermatitis; the older sedating antihistamines might work better. Tricyclic antidepressants such as doxepin have antihistamine activity in addition to central effects and are useful in chronic, severe pruritus.

Gabapentin, buspirone, and selective serotonin reuptake inhibitors SSRIs may be considered in select patients. Ultraviolet UV B phototherapy is very effective in uremic pruritus and may be helpful in patients with prurigo nodularis, atopic dermatitis, HIV infection, and aquagenic pruritus. Opioid-receptor antagonists, such as naloxone, have occasionally been used for intractable pruritus of renal and cholestatic diseases. Other measures that have been tried for chronic pruritus are acupuncture and transcutaneous electrical nerve stimulation TENS see Box 4.

Aggressive treatment of the eczema may be the only way to control the pruritus in patients with atopic dermatitis. Limited use of systemic corticosteroids as well as other systemic immunosuppressives may be needed to treat the eczema. Other than general treatments as mentioned earlier, mild disease might respond to UVB phototherapy and erythropoietin. Second-line treatments include oral activated charcoal, cholestyramine, and the opioid antagonist naltrexone.

Third-line therapies include thalidomide and parathyroidectomy. Dialysis can provide some relief but rarely improves itching significantly. Parathyroid hormone levels have been found to be increased and have been implicated as a cause. These patients experience relief of pruritus after parathyroidectomy. Ion-exchange resins, such as cholestyramine, probably act by lowering levels of bile salts and other pruritogens.

Altered central opioidergic neurotransmission is believed to be a contributing factor, 12 and opioid antagonists such as naloxone and naltrexone have been found useful. Third-line treatment includes UVB phototherapy, extracorporeal albumin dialysis, plasmapheresis, and dronabinol, a cannabinoid. Antihistamines are usually ineffective, but psoralen plus ultraviolet A PUVA phototherapy has been helpful in some patients. Aspirin has been reported effective, and a trial showed SSRIs to be effective. You're likely to start by seeing your family doctor or primary care doctor.

In some cases, you may be referred to a specialist in skin diseases dermatologist. Here is information to help you get ready for your appointment and to know what to expect from your doctor. Write down your signs and symptoms, when they occurred, and how long they lasted. Also, make a list of all medications, including vitamins, herbs and over-the-counter drugs, you're taking. Or take the original bottles and a written list of the dosages and directions.

Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission. This content does not have an English version. This content does not have an Arabic version. Diagnosis Tracking down the cause of your itch can take time and involve a physical exam and questions about your medical history. If your doctor thinks your itchy skin is the result of a medical condition, you might have tests, including: Blood test. A complete blood count can provide evidence of an internal condition causing your itch, such as iron deficiency.

Tests of thyroid, liver and kidney function. Liver or kidney disorders and thyroid abnormalities, such as hyperthyroidism, may cause itching. Chest X-rays. A chest X-ray can show if you have enlarged lymph nodes, which can go along with itchy skin. More Information Chest X-rays. Request an Appointment at Mayo Clinic.

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What ingredient should you look for? Share on: Facebook Twitter. References Fazio SB, et al. Pruritis: Overview of management.

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    Efficacy of Gabapentin in the Management of Pruritus of Unknown Origin

    Rochester, Minn. Goldsmith LA, et al. Pathophysiology and clinical aspects of pruritus. In: Fitzpatrick's Dermatology in General Medicine.

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