Itching: A Merck Manual of Patient Symptoms podcast
Itching is a symptom that can cause significant discomfort and is one of the most common reasons for consultation with a dermatologist. Itching leads to scratching, which can cause inflammation, skin degradation, and possible secondary infection. The skin can become lichenified, scaly, and excoriated.
Itch can be prompted by diverse stimuli, including light touch, vibration, and wool fibers. There are a number of chemical mediators as well as different mechanisms by which the sensation of itch occurs.
Histamine is one of the most significant mediators. It is synthesized and stored in mast cells in the skin and is released in response to various stimuli. Other mediators (eg, neuropeptides) can either cause the release of histamine or act as pruritogens themselves, thus explaining why antihistamines ameliorate some cases of itching and not others. Opioids have a central pruritic action as well as stimulating the peripherally mediated histamine itch.
There are 4 mechanisms of itch:
Intense itching stimulates vigorous scratching, which in turn can cause secondary skin conditions (eg, inflammation, excoriation, infection), which can lead to more itching. However, scratch can temporarily reduce the sensation of itch by activating inhibitory neuronal circuits.
Itching can be a symptom of a primary skin disease or, less commonly, a systemic disease (see Table 1: Approach to the Dermatologic Patient: Some Causes of Itching).
Many skin disorders cause itching. The most common include
In systemic disorders, itching may occur with or without skin lesions. However, when itching is prominent without any identifiable skin lesions, systemic disorders and drugs should be considered more strongly. Systemic disorders are less often a cause of itching than skin disorders, but some of the more common causes include
Less common systemic causes of itching include hyperthyroidism, hypothyroidism, diabetes, iron deficiency, dermatitis herpetiformis, and polycythemia vera.
Drugs can cause itching as an allergic reaction or by directly triggering histamine release (most commonly morphine, some IV contrast agents).
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History of present illness should determine onset of itching, initial location, course, duration, patterns of itching (eg, nocturnal or diurnal, intermittent or persistent, seasonal variation), and whether any rash is present. A careful drug history should be obtained; both oral (eg, opioids, cocaine, aspirin, prescription and OTC) and topical (eg, hydrocortisone, benadryl, moisturizers) drugs are included. History also should include any factors that make the itching better or worse.
Review of systems should seek symptoms of causative disorders, including steatorrhea and right upper quadrant pain (cholestasis); constitutional symptoms of fever, weight loss, and night sweats (cancer); intermittent weakness, numbness, tingling, and visual disturbances or loss (multiple sclerosis); irritability, sweating, weight loss, and palpitations (hyperthyroidism) or depression, dry skin, and weight gain (hypothyroidism); urinary frequency, excessive thirst, and weight loss (diabetes); and headache, pica, hair thinning, and exercise intolerance (iron deficiency anemia).
Past medical history should identify known causative disorders (eg, renal disease, cholestatic disorder, cancer being treated with chemotherapy) and the patient's emotional state. Social history should focus on family members with similar itching and skin symptoms (eg, scabies, pediculosis); relationship of itching to occupation or exposures to plants, animals, or chemicals; and history of recent travel.
Physical examination begins with a review of clinical appearance for signs of jaundice, weight loss or gain, and fatigue. Close examination of the skin should be done, taking note of presence, morphology, extent, and distribution of lesions. Cutaneous examination also should make note of signs of secondary infection (eg, erythema, swelling, warmth, yellow or honey-colored crusting).
The examination should make note of significant adenopathy suggestive of cancer. Abdominal examination should focus on organomegaly, masses, and tenderness (cholestatic disorder or cancer). Neurologic examination should focus on weakness, spasticity, or numbness (multiple sclerosis).
The following findings are of particular concern:
Interpretation of findings
Generalized itching that begins shortly after use of a drug is likely caused by that drug. Localized itching (often with rash) that occurs in the area of contact with a substance is likely caused by that substance. However, many systemic allergies can be difficult to identify because patients typically have consumed multiple different foods and have been in contact with many substances before developing itching. Similarly, identifying a drug cause in a patient taking several drugs may be difficult. Sometimes the patient has been taking the offending drug for months or even years before developing a reaction.
If an etiology is not immediately obvious, the appearance and location of skin lesions can suggest a diagnosis (see Table 1: Approach to the Dermatologic Patient: Some Causes of Itching).
In the minority of patients in whom no skin lesions are evident, a systemic disorder should be considered. Some disorders that cause itching are readily apparent on evaluation (eg, chronic renal failure, cholestatic jaundice). Other systemic disorders that cause itching are suggested by findings (see Table 1: Approach to the Dermatologic Patient: Some Causes of Itching). Rarely, itching is the first manifestation of significant systemic disorders (eg, polycythemia vera, certain cancers, hyperthyroidism).
Many dermatologic disorders are diagnosed clinically. However, when itching is accompanied by discrete skin lesions of uncertain etiology, biopsy can be appropriate. When an allergic reaction is suspected but the substance is unknown, skin testing (either prick or patch testing depending on suspected etiology) is often done. When a systemic disorder is suspected, testing is directed by the suspected cause and usually involves CBC; liver, renal, and thyroid function measurements; and appropriate evaluation for underlying cancer.
Any underlying disorder is treated. Supportive treatment involves the following (see also Table 2: Approach to the Dermatologic Patient: Some Therapeutic Approaches to Itching):
Itching due to any cause benefits from use of cool or lukewarm (but not hot) water when bathing, mild or moisturizing soap, limited bathing duration and frequency, frequent lubrication, humidification of dry air, and avoidance of irritating or tight clothing. Avoidance of contact irritants (eg, wool clothing) also may be helpful.
Topical drugs may help localized itching. Options include lotions or creams that contain camphor and/or menthol, pramoxine, or corticosteroids. Corticosteroids are effective in relieving itch caused by inflammation but should be avoided for conditions that have no evidence of inflammation. Topical benzocaine, diphenhydramine, and doxepin should be avoided because they may sensitize the skin.
Systemic drugs are indicated for generalized itching or local itching resistant to topical agents. Antihistamines, most notably hydroxyzine, are effective, especially for nocturnal itch, and are most commonly used. Sedating antihistamines must be used cautiously in elderly patients during the day because they can lead to falls; newer nonsedating antihistamines such as loratadine, fexofenadine, and cetirizine can be useful for daytime itching. Other drugs include doxepin (typically taken at night due to high level of sedation), cholestyramine (for renal failure, cholestasis, and polycythemia vera), opioid antagonists such as naltrexone (for biliary pruritus), and possibly gabapentin (for uremic pruritus).
Physical agents that may be effective for itching include ultraviolet phototherapy.
Xerotic eczema is very common among elderly patients. It is especially likely if itching is primarily on the lower extremities.
Severe, diffuse itching in the elderly should raise concern for cancer, especially if another etiology is not immediately apparent.
When treating the elderly, sedation can be a significant problem with antihistamines. Use of nonsedating antihistamines during the day and sedating antihistamines at night, liberal use of topical ointments and corticosteroids (when appropriate), and consideration of ultraviolet phototherapy can help avoid the complications of sedation.
Last full review/revision March 2013 by Robert J. MacNeal, MD