Pruritus is the sensation that provokes a desire to scratch. Pruritus as a medical complaint is 40% as common as low back pain. Elderly Asian men are most significantly affected, with 20% of all health care visits in Asian men over the age of 65 involving the complaint of itch. The quality of life of a patient with chronic pruritus is the same as a patient undergoing hemodialysis. Evidence suggests that increased interleukin-31 (IL-31) signaling through the IL-31 receptor on epithelial cells and keratinocytes is associated with itch, especially in allergic skin disease. It also appears that Il-4 and Il-13 (via binding to the Il-4R) lower the itch threshold of sensory neurons. Janus kinase signaling (which occurs downstream from the Il-4R) is also emerging as important in the pathophysiology of itch.
Dry skin is the first cause of itch that should be sought, since it is common and easily treated. The next step in physical evaluation of the itchy patient is deciding whether a primary skin lesion is present or absent. If a primary skin lesion is present, then the patient has a primary cutaneous disease with associated pruritus. Examples of primary cutaneous pruritic diseases include scabies, atopic dermatitis, insect bites, pediculosis, contact dermatitis, drug reactions, urticaria, psoriasis, lichen planus, and fiberglass dermatitis. These conditions all present with recognizable cutaneous morphologies, and the treatment of the skin condition usually results in control of the associated pruritus.
Persistent pruritus not explained by cutaneous disease or association with a primary skin eruption should prompt a staged workup for systemic causes. Common causes of pruritus associated with systemic diseases include endocrine disorders (eg, hypothyroidism, hyperthyroidism, or hyperparathyroidism), psychiatric disturbances, lymphoma, leukemia, and other internal malignant disorders, iron deficiency anemia, HIV, hypercalcemia, cholestasis, and certain neurologic disorders. Calcium channel blockers can cause pruritus with or without eczema, even years after they have been started, and it may take up to 1 year for the pruritus to resolve after the calcium channel blocker has been stopped.
The treatment of chronic pruritus can be frustrating. Most cases of pruritus are not mediated by histamine, hence the poor response of many pruritic patients to antihistamines. Emollients for dry skin are listed in Table 6–2. Emollient creams (preferred over lotions) should be generously applied from neck to toe immediately after towel drying and again one more time per day. Neuropathic disease, especially in diabetic patients, is associated with pruritus, making neurally acting agents, such as gabapentin (starting at 300 mg orally at around 4 PM and a second dose of 600 mg orally at bedtime) or pregabalin (150 mg orally daily), attractive approaches to the management of pruritus. Combinations of antihistamines, sinequan, gabapentin, pregabalin, mirtazapine, and opioid antagonists can be attempted in refractory cases. In cancer-associated and other forms of pruritus, aprepitant (Emend) 80 mg orally daily for several days can be dramatically effective. The uremia in conjunction with hemodialysis ...