Dr Nadeem Ahmed Khan Niazi
MBBS, M.Sc Clinical Dermatology (London)
Fauji Foundation Hospital
Rawalpindi
PRURITIS
Please correct
PRURITUS
Sensation that provokes desire to scratch
Almost always unpleasant
Localized,
generalized,
paroxysmal
unremitting
Burning,
tingling
pricking
NEUROPHYSIOLOGY
Polymodal unmyelinated C fibers
Dorsal horn of spinal cord
Spinothalmic tract
Cerebral cortex
Mediators
Histamine
Serotonin
Cytokines
Opioids
Pruritus as a diagnosis
Itching without a specific rash
Accompanied by no visible skin alterations
other than those produced by scratching
ETIOLOGY
Dermatological
Systemic
Neurophsychiatric
DERMATOLOGICAL
DISORDERS
Local disorders
Generalised disorders
LOCAL DISORDERS
Atopic Dermatitis
Xerosis
Contact dermatitis
Urticaria
Insect bite reaction
Lichen Planus
Prurigo nodularis
Dermatitis Herpetiformis
Lichen Simplex Chronicus
INFCETIONS AND
INFESTATIONS
Candidiasis
Varicella
Pediculosis capitis
GENERALISED DISORDERS
Winter itch
Pruritus of Senescent skin
Infestations
Scabies
Drugs
Psychogenic states
SYSTEMIC DISORDERS
ENDOCRINE DISORDERS
Hyper and Hypothyroidism
Diabetes mellitis
Iron Deficiency Anaemia
Polycythemia rubra vera
Haemochromatosis
HEPATIC DISORDERS
Obstructive biliary disease
Cholestatic liver disease of pregnancy
INFECTIONS
HIV
Hepatitis C
Trichinosis
NEOPLASTIC DISEASES
Cutaneous T Cell Lymphomas
Hodgkins / Non Hodgkins Lymphoma
Leukemia
Carcinoid syndrome
Multiple myeloma
Internal malignant tumors ( lung, breast
and gastric )
Neurologic
Peripheral nerve injuries
PHN
Psychosis
Depression
Multiple sclerosis
RENAL DISORDERS
Chronic Renal Failure
MISCELLANEOUS
Soaps and detergents
Other external agents
MANAGEMENT
HISTORY
Pruritus: nature, onset, duration
Systemic review
Drug history
EXAMINATION
Liver
Spleen
Thyroid
Lymph nodes
Cutaneous examination
Butterfly sign: sparing of skin of upper back
INVESTIGATIONS
RELEVANT
IF PRURITUS PERSISTS > 3 MONTHS
INITIAL SCREEN
CBC with differential
Liver & renal function
Hepatitis C screen
TFT
Urinalysis
Occult blood in stool for patients over 40 years
Chest X-ray
HIV testing
Skin biopsy
TREATMENT
General measures
Removing the basic cause
Local applications
Oral antihistamines
GENERAL MEASURES
Trim nails regularly
Mild soap for bathing followed by gentle
drying
Limit bathing frequency & duration
Use of emollients
Topical Antipruritic Agents
Doxepin
Menthol
Phenol
Pramoxine hydrochloride
Capscin
Anti histamines
First Generation Anti histamines
Chlorpheniramine melate
Pheniramine melate
Clemastine fumarate
Promethazine hydrochloride
Trimeprazine tartrate
Cyproheptadine hydrochloride
Hydroxyzine hydrochloride
Second Generation Anti histamines
Terfenadine
Astemizole
Cetirizine (Zeatin / Zyrtec)
Loratadine (Softin)
Fexofenadine (Telfast)
Acrivastine
Ebastine (Kestine)
Some novel agents
Butorphenol
Naltrexone
Paroxetine
Sertraline
Fluoxetine
Mirtazapine
Gabapentine
Thalidomide
Take away
message
Pruritus may be a symptom of
systemic diseas
Or may be a symptom of malignancy
May precede by five years
Review an itchy patient every 3 to 6
months
Failure to detect a
systemic cause could be
considered negligence
