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Patient information: ruritus is the subjective sensation substances that can cause skin lesions. New
A handout on pruritus, of itching. It can become severe cosmetics and creams can trigger allergic
written by the authors of
this article, is provided on enough to interfere with work and contact dermatitis, urticaria, and photo-
page 203. restful sleep. Histamine is the pri- dermatitis. New drugs (medications, nutri-
mary mediator of itching in many disorders.1 tional supplements, illicit drugs) can lead to
Antihistamines are effective in treating urticaria or fixed drug eruptions. Travel can
histamine-mediated pruritus, but they expose a person to new foods that can trig-
may be less effective in patients with dis- ger urticaria and to sunlight that can trigger
eases that trigger pruritus through mecha- photodermatitis. Travelers are also suscep-
nisms involving serotonin, leukotrienes, or tible to infestations, such as with scabies or
neuropeptides.1,2 lice. Hobbies may expose the skin to solvents
and topical agents that can trigger contact
Evaluation dermatitis. Chronic occupational exposure
The initial clinical approach in patients to solvents can dry the skin, causing xerosis
with pruritus includes a history and physi- and atopic dermatitis or eczema. New ani-
cal examination to determine if the pruritus mal exposures can lead to flea infestations,
is caused by a dermatologic condition or is allergic cutaneous reactions to dander, and
secondary to an underlying systemic dis- urticaria. Another important finding in
ease. Figure 1 is a diagnostic algorithm for the evaluation of patients with pruritus is a
pruritus. recent exposure to sick contacts who have
The presence of a primary skin lesion may febrile diseases, such as rubeola, mumps, or
aim the evaluation toward a dermatologic varicella, or exposure to infectious organisms
cause. The history should focus on recent that can cause rashes, such as parvovirus,
exposures to new topical, oral, or airborne Staphylococcus aureus, or Streptococcus
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Familyrequests.
Pruritus
196 American Family Physician www.aafp.org/afp Volume 84, Number 2 July 15, 2011
Pruritus
Evidence
Clinical recommendations rating References
July 15, 2011 Volume 84, Number 2 www.aafp.org/afp American Family Physician 197
Pruritus
Table 2. Dermatologic Etiologies for Pruritus
Etiology Features
Atopic dermatitis Pruritic area where rash appears when scratched in patients with atopic
conditions (e.g., allergic rhinitis, asthma)
Involvement of flexor wrists and ankles, as well as antecubital and
popliteal fossae
Cutaneous T-cell Oval eczematous patch on skin with no sun exposure (e.g., buttocks)
lymphoma (mycosis Possible presentation of new eczematous dermatitis in older adults
fungoides) Possible presentation of erythroderma (exfoliative dermatitis)
Dermatitis Rare vesicular dermatitis affecting the lumbosacral spine, elbows, or knees
herpetiformis
Dermatophyte Localized pruritus and rash characterized by peripheral scaling and central
infection clearing
Can occur on several sites, including the feet, scalp, trunk, and groin
Psoriasis Plaques on extensor extremities, low back, palms, soles, and scalp
198 American Family Physician www.aafp.org/afp Volume 84, Number 2 July 15, 2011
Pruritus
for most types of urticaria, although other patients with nasopharynx, prostate, stom-
immunohistochemicals may play an impor- ach, breast, brain, uterine, or colon cancer.5,27
tant role in more chronic cases.18 Peripheral or Central Nervous System. Pru-
Xerosis. Xerosis is the most common cause ritus can also arise from diseases or disorders
of pruritus in the absence of an identifiable of the peripheral or central nervous system,
skin lesion. It is characterized by dry, scaly such as multiple sclerosis, neuropathy, and
skin, usually on the lower extremities and in nerve compression or irritation (e.g., notalgia
axillary creases, and most often occurs in the paresthetica, brachioradial pruritus).28
winter months. Associated factors include Pregnancy. Pregnancy-related dermatoses
older age, frequent bathing, use of hot water (Table 41-7,29-35) represent a heterogeneous
when bathing, and exposure to high ambient group of pruritic inflammatory skin diseases
temperatures with relatively low humidity.20 related to pregnancy or the postpartum
period. Some dermatoses cause only intense
COMMON SYSTEMIC CAUSES pruritus and skin lesions (e.g., polymorphic
Pruritus in the absence of a primary derma- eruption of pregnancy, atopic eruption of
tologic etiology may be indicative of a seri- pregnancy), but others can cause significant
ous underlying systemic disease.4 Studies fetal risks, including prematurity, growth
have shown that 14 to 24 percent of patients restriction, fetal distress, and intrauterine
presenting to a dermatologists office with fetal demise (e.g., intrahepatic cholestasis
pruritus and no primary dermatologic cause of pregnancy, pemphigoid gestationis).29-37
have a systemic condition.4,9,21-24 However,
pruritus is often overemphasized as an early
manifestation of cancer.4,21 Table 3. Systemic Etiologies for Pruritus
Chronic Renal Disease. More than 50 per-
cent of patients with chronic renal disease Autoimmune Malignancy
and up to 80 percent of patients on dialysis Dermatitis herpetiformis Leukemia
have pruritus.2 The pruritus is often general- Dermatomyositis Lymphoma
ized, but may be localized to the back.25 Linear immunoglobulin A disease Multiple myeloma
Liver Disease. Pruritus caused by impaired Sjgren syndrome Solid tumors with
paraneoplastic syndrome
bile secretion is a common symptom in sev- Hematologic
eral forms of liver disease. It can be gener- Hemochromatosis Metabolic and endocrine
alized, but is typically worse on the palms Iron deficiency anemia Carcinoid syndrome
and soles. Associated conditions include Mastocytosis Chronic renal disease
primary biliary cirrhosis, sclerosing cholan- Plasma cell dyscrasias Diabetes mellitus
gitis, viral hepatitis, drug-induced cholesta- Polycythemia vera Hyper/hypothyroidism
sis, and other causes of obstructive jaundice. Hepatobiliary Hyperparathyroidism
Biliary obstruction leads to pruritus in Biliary cirrhosis Neurologic
these disorders, but there is little correlation Chronic pancreatitis with obstruction Cerebral abscess
between serum bilirubin level and severity of of biliary tracts Cerebral tumor
pruritus.26 Drug-induced cholestasis Multiple sclerosis
Malignancy. The possibility of an under- Hepatitis, particularly hepatitis C Stroke
lying malignant disease should be consid- Sclerosing cholangitis
Other
ered in patients with generalized pruritus of Infectious disease Drug ingestion
unknown cause. Among malignant diseases, AIDS Eating disorders with rapid
Hodgkin lymphoma has the strongest asso- Infectious hepatitis weight loss
ciation with pruritus, which occurs in up to Parasitic disease (giardiasis, onchocerciasis, Neuropsychiatric disorders
30 percent of patients with the disease.10 Pru- schistosomiasis, ascariasis) Pregnancy
ritus can precede the clinical presentation of Prion disease
lymphoma by up to five years and is often
the presenting symptom.5 Pruritus has been Information from references 2, 3, 5, 7, 9, and 10.
reported as a paraneoplastic manifestation in
July 15, 2011 Volume 84, Number 2 www.aafp.org/afp American Family Physician 199
Pruritus
Atopic Prurigo, early-onset prurigo, Second trimester (75 percent Two-thirds of patients have widespread
eruption of pruritic folliculitis, or eczema of of patients affected before eczematous changes, mainly on flexural
pregnancy pregnancy; prurigo gestationis third trimester) sites1,2
Tends to recur in subsequent One-third of patients have focal lesions;
pregnancies follicular, papular, or pustular
Generalized xerosis
Intrahepatic Cholestasis of pregnancy, obstetric Third trimester Sudden onset of intense pruritus
cholestasis of cholestasis, jaundice of pregnancy, Tends to recur in subsequent Often starts on palms or soles, then
pregnancy1,2 pruritus gravidarum, prurigo pregnancies becomes generalized
gravidarum, icterus gravidarum Only secondary skin changes from
scratching are apparent
Pemphigoid Herpes gestationis Third trimester or postpartum Intense pruritus precedes urticarial plaques
gestationis Tends to recur in subsequent or papules surrounding umbilicus
pregnancies Spreads rapidly and forms bullae
Polymorphic Pruritic urticarial papules and Late third trimester and Mainly papulourticarial
eruption of plaques, polymorphic eruption, postpartum, most often in Starts within striae, coalesces into plaques,
pregnancy toxic erythema, toxemic rash, or primigravida and spreads to buttocks and proximal
late-onset prurigo of pregnancy Does not tend to recur in thighs; spares umbilical region
subsequent pregnancies
200 American Family Physician www.aafp.org/afp Volume 84, Number 2 July 15, 2011
Pruritus
Elevated total serum bile acid levels Fetal risks include prematurity (19 to 60 percent),
intrapartum fetal distress (22 to 33 percent),
and fetal demise (1 to 2 percent) 6,7
Close monitoring with delivery after lungs mature
reduces fetal risks
Maternal risks include steatorrhea with vitamin K
deficiency and bleeding complications
The conditions that can lead to pruritus Program at Offutt Air Force Base, Neb. He is also an assis-
are extensive. Distinguishing between pru- tant professor in the Department of Family Medicine at the
Uniformed Services University of the Health Sciences and
ritus with a specific dermatologic cause and at the University of Nebraska Medical Center in Omaha.
pruritus that is a manifestation of a systemic
STACY FLETCHER, CAPT, USAF, MC, is a staff physician in
disease can facilitate efficient diagnosis and the Ehrling Bergquist Family Medicine Residency Program.
treatment, leading to a rapid resolution of She is also an assistant professor in the Department of Fam-
symptoms for most patients. Treatment ily Medicine at the University of Nebraska Medical Center.
options for specific etiologies of pruritus are Address correspondence to Brian V. Reamy, MD, FAAFP,
beyond the scope of this article. Uniformed Services University of the Health Sciences,
4301 Jones Bridge Rd., Bethesda, MD 21037 (e-mail:
The opinions and assertions contained herein are the breamy@usuhs.mil). Reprints are not available from the
private views of the authors and are not to be construed authors.
as official or as reflecting the views of the U.S. Air Force
Medical Department or the U.S. Air Force at large. Author disclosure: No relevant financial affiliations to
disclose.
The Authors
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202 American Family Physician www.aafp.org/afp Volume 84, Number 2 July 15, 2011