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Approaching the Pruritic Patient

»	What is the most common symptom of dermatologic disease?
»	What is an “itch”?
»	Is an itch a separate modality of pain or a submodality of pain?
»	What causes an itch?
»	Describe the difference between localized and generalized pruritus.
»	What is the best approach to evaluation of a patient with localized pruritus?
»	What are the common causes of localized pruritus?
»	What is notalgia paresthetica?
»	What is the physician’s best approach when seeing a patient with generalized pruritus?
»	After obtaining a complete history and physical examination, what clinically oriented classification scheme should be followed?
»	What are common causes of generalized pruritus?
»	How prevalent is an underlying systemic disease in a patient who seeks medical attention for pruritus?
»	What is “winter itch”? In which patient population is it common?
»	The patient complains that “wool makes me itch” or “I am allergic to wool.” What disease does this patient probably have?
»	What treatment should the physician consider if a patient presents with pruritus and “hives”?
»	What disease should the physician consider if the patient volunteers that his spouse also suffers from itching?
»	Is pruritus in HIV-infected patients common? What are the common causes of pruritus in these patients?
»	Which psychiatric disorder often presents with intractable pruritus?
»	Which patients with renal failure experience “renal itch”?
»	Which patients with liver disease are most likely to experience pruritus? What is the best screening laboratory test?
»	What are the common causes of cholestic pruritus?
»	Which hematologic disorders are known to present with pruritus?
»	Is generalized pruritus a common symptom of endocrine disorders?
»	Can itching cause skin disease?
»	What is the best symptomatic treatment for a patient with pruritus?

What is the best symptomatic treatment for a patient with pruritus?

The best treatment for a patient with pruritus involves identifying an underlying dermatosis or systemic disorder responsible for the pruritus and treating that disease. All patients should be advised about appropriate skin care, which includes adequate nutrition and daily fluid intake, protection from the environment, and cleansing practices that do not dry the skin. In addition to the skin care factors, medications applied to the skin or taken by mouth may be necessary to treat pruritus. Topical agents containing menthol produce a cooling sensation. Topical agents containing phenol or camphor have local anesthetic effects. Pramoxine, another topical anesthetic, can provide relief. If appropriate, topical corticosteroids can be used for local control. Oral antihistamines, such as hydroxyzine or doxepin, are commonly used and often provide the first-line treatment for pruritus with no identifiable cause. Other less traditional therapies and techniques are reserved for refractory cases and are best reserved for the practicing clinical dermatologist to address (Table 67-3).

All patients should be advised regarding the avoidance of scratching to focus on interrupting the itch-scratch-itch cycle. Breaking the itch-scratch-itch cycle (an increase in itching that can result from the process of scratching) may also help to alleviate pruritus. The cycle may be broken by applying a cool washcloth or ice over the affected area.

Greece PJ, Ende J: Pruritus: a practical approach, J Gen Intern Med 7:340–349, 1992.

Table 67-3. Treatment of Pruritus
	Topical	Cooling agents, emollients, topical corticosteroids, anesthetics
	Systemic	Antihistamines, systemic corticosteroids, opioid receptor antagonists
	Phototherapy	Ultraviolet B (UVB), narrowband UVB (NBUVB)
	Miscellaneous	Transcutaneous electrical nerve stimulation (TENS), acupuncture, capsaicin