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Itching

(Pruritus)

By

Julia Benedetti

, MD, Harvard Medical School

Last full review/revision Feb 2019| Content last modified Feb 2019
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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.

Pathophysiology of Itching

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. Specific peripheral sensory neurons mediate the itch sensation. These neurons are distinct from those that respond to light touch or pain; they contain a receptor, MrgA3, the stimulation of which causes the sensation of itching.

Mediators

Histamine is the well-known mediator. 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.

Mechanisms

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 through disruption of the skin barrier. Although scratching can temporarily reduce the sensation of itch by activating inhibitory neuronal circuits, it also leads to amplification of itching at the level of the brain, exacerbating the itch–scratch cycle.

Etiology of Itching

Skin disorders

Systemic disorders

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

Drugs

Evaluation of Itching

History

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 including both prescription and over-the-counter medications with particular attention paid to recently started drugs. The patient's use of moisturizers and other topicals (eg, hydrocortisone, diphenhydramine) should be reviewed. History should include any factors that make the itching better or worse

Review of systems should seek symptoms of causative disorders, including

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

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).

Red flags

The following findings are of particular concern:

  • Constitutional symptoms of weight loss, fatigue, and night sweats

  • Extremity weakness, numbness, or tingling

  • Abdominal pain and jaundice

  • Urinary frequency, excessive thirst, and weight loss

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.

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: Some Causes of Itching Some Causes of Itching 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... read more ). Rarely, itching is the first manifestation of significant systemic disorders (eg, polycythemia vera, certain cancers, hyperthyroidism).

Testing

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.

Treatment of Itching

  • Local skin care

  • Topical treatment

  • Systemic treatment

Skin care

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 clothing. Avoidance of contact irritants (eg, wool clothing) also may be helpful.

Topical drugs

Topical drugs may help localized itching. Options include lotions or creams that contain camphor and/or menthol, pramoxine, capsaicin, 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

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.

Table
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Geriatrics Essentials

Age-related changes in the immune system and in nerve fibers may contribute to the high prevalence of itch in older adults.

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.

Key Points

  • Itching is usually a symptom of a skin disorder or systemic allergic reaction but can result from a systemic disorder.

  • If skin lesions are not evident, systemic causes should be investigated.

  • Skin care (eg, limiting bathing, avoiding irritants, moisturizing regularly, humidifying environment) should be observed.

  • Symptoms can be relieved by topical or systemic drugs.

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