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  icon Rare
  icon Not so common
  icon Common
  icon Low morbidity
  icon Considerable morbidity
  icon Serious


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  • Persistent severe pruritus, like pain, is a dominating factor in existence; from day to day it takes over one's life. Intense pruritus may, in fact, be more maddening for the patient than pain.
  • The physician, therefore, often feels somewhat helpless in the management of these unfortunate patients.
  • Pruritus leads to sleepless nights; a state of permanent fatigue ensues that precludes work and confounds family relationships. Most skin eruptions and rashes are more or less pruritic, but there are states where there is severe pruritus in the absence of skin lesions, except for scratch marks (Fig. 36-1). This is called pruritus sine materia (from Latin, “itch without physical substrate”).
  • The diagnostic approach to the patient with generalized pruritus without identifiable skin lesions is a diagnosis of exclusion.
  • This pruritus may be intrinsic to the skin but not due to a skin disease with specific lesions.
  • It may be a symptom of a skin disease that at the time of examination does not manifest with specific lesions.
  • It may be due to an internal organ disease, metabolic and endocrine conditions, or hematologic disease.
  • It may be a manifestation of malignant tumors, psychogenic states, or HIV-1 infection; or it may be related to injected or ingested drugs.
  • The various causes of pruritus sine materia are listed in Table 36-1, and an algorithm of how to approach a patient with pruritus sine materia is shown in Table 36-2.
  • A careful history and physical examination are essential and should take into account the different types of itching and their duration, the quality of itching, and its distribution and timing.
  • It is understood that any patient referred with generalized pruritus without skin lesions should be assumed to have minimal or latent disease of the skin until proven otherwise.
  • Skin signs may be clinically inapparent, perhaps confined to only circumscribed areas, and this is particularly important with regard to the exclusion of scabies, pediculosis, or conditions such as urticaria factitia.

Figure 36-1
Graphic Jump Location

Pruritus without diagnostic skin lesions This patient had multiple scratch marks due to compulsive scratching because of severe pruritus. There were no other, and in particular, diagnostic lesions. Workup revealed biliary cirrhosis without jaundice.

Table Graphic Jump Location
Table 36-1 Causes of Pruritus Sine Materia

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