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In the name of God

In the name of God. pruritus. Dr Z.Shahmoradi. خارش:. - شایع ترین علامت پوستی است که به درجات مختلفی در انواع درماتوزها و نیز گاهی دربیماریهای داخلی دیده می شود. خارش یک حس ناخوشایند در پوست (و گاهی مخاط و قرنیه)است که بیمار را وادار یا متمایل به خراشیدن یا مالیدن پوست می کند.

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In the name of God

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  1. In the name of God pruritus DrZ.Shahmoradi

  2. خارش: - شایع ترین علامت پوستی است که به درجات مختلفی در انواع درماتوزها و نیز گاهی دربیماریهای داخلی دیده می شود. خارش یک حس ناخوشایند در پوست (و گاهی مخاط و قرنیه)است که بیمار را وادار یا متمایل به خراشیدن یا مالیدن پوست می کند. حس خارش توسط محرکهای مختلف شامل: شیمیایی،حرارتی،مکانیکی، الکتریکی و نیز لمس سطحی،تغییرات دما و استرس ایجاد یا تشدید می شود.

  3. حس خارش و درد توسط انتهاهای عصبی که نزدیک جانکشن درم و اپیدرمال است،دریافت می شود. فیبرهای C، انتقال دهنده خارش از رسپتورهای پوستی بوده که این فیبرهای پلی مودال و غیرمیلینه وارد شاخ خلفی نخاع شده و با نرون ثانوی سیناپس کرده و پس از تقاطع، از راه اسپینوتالامیک به تالاموس رفته و از آنجا نرون سوم ،حس خارش را به کورتکس می برد.

  4. Histamine receptors • H1 (smooth muscle, endothelial cells ,nerve fibers ,acute allergic responses) • H2( gastric parietal cells secretion of gastric acid , T helpers) • H3 (central nervous system,presynaptic neurons modulating neurotransmission ) • H4 (mast cells, eosinophils, T cells, dentritic cells regulating immune responses)

  5. Is the most common symptom of patients coming to dermatologic clinics. • Causes: • 1-skin disease: (Lichen planus, Pediculosis, Scabies, Atopic dermatitis,Urticaria,…) mild to moderate :psoriasis, seborrhea, photodermatitis severe: lichen planus, atopic, neurodermatitis Rubbing: urticaria, lichen planus, post menopause • 2-Systemic.D: (CRF,CBD,…( • 3-Senile & winter .P

  6. Systemic causes ofpruritus

  7. Itch in response to systemic internal disease (neurogenic itch)

  8. 1-Chronic renal failure • Most of CRF patients & 80% of hemodialysis patients have pruritus. • The cause is unknown(uremia, dry skin ,increased skin mast cells & histamine release, secondary hyper parathyroidism,aluminium overload [treatable by desferrioxamine],hypervitaminosis A, neuropathy, substance –P, serotonin, ….)

  9. خارش کلیوی: - ارتباطی با سن،جنس،نژاد،مدت دیالیز و علت نارسایی کلیه ندارد. - دیالیز صفاقی کمتر از همودیالیز ایجاد خارش می کند. - اوج خارش، دو روز پس از همودیالیز است و شبها شدیدتر می شود.

  10. Treatment: • -Emollient • UVB therapy (depletes the vit.A ) • -Activated charcoal (6g/d for 8wks)

  11. -Renal transplantation - parathyroidectomy, Heparin, lidocain (200mg in 100cc normal saline slow iv infusion) , mexiletine, ion-change resins, topical capsaicin 0.025% 3-5 times daily • -Antihistamines & topical steroidesnot helpful

  12. …Treatment: • Topical gamma-linoleic acid (2.2%, 4 times daily) • Gabapentin(200-300 mg aftereach hemodialysis session) • Cholestyramine (4-16g poqd in divided doses 30 minute before meal) • Ondansetron(4-8mg iv, then 4mg orally every 8 hours) • Nalfurafine (kappa-opioid receptor agonist): 5 micro g iv 3 times a wk (post hemodialysis) • Ketotifen (1-2 mg poqd) • Thalidomide (100 mg poqd) • Erythropoietin (36 U/kg sc3 times a wk)

  13. Treatments for pruritus of chronic renal failure.

  14. 2-Cholestatic biliary disease • In 20-50% of cholestasis & hepatitis C & other hepatitis , primary biliary cirrhosis, primary sclerosing cholangitis, obstructive choleducholithiasis, carcinoma of the bile duct • Generalized, migratory, not relieved with scratching • Worse on the hands & feet and body regions constricted by clothing, at night • In chronic cholestasis: can be early symptom developing years before any other manifestations.

  15. Cause: unknown,percipitation of specific bile salts with specific concentration in skin.(not always) - Increased opioidergicneurotransmisson or neuromodulation in the CNS (opiate agonists induce opioid receptor-mediated scratching activity of central origin)

  16. Treatment: • -Cholestyramin (powder=4g) 3 times 30 minute before meal may be improved pruritus in PCV & uremia • + rifampicin (10mg/kg/d or 300mg Bid), • -UVB phototherapy • Naloxone (1ml=0.4mg) 0.8ml ID • Plasmapheresis • Ribaverin : in chronic hepatitis C • liver transplantation

  17. Terfenadine & cholestyramine • Phenobarbital (2-5 mg/kg/d) & rifampicin, ondancetron • Antihistamine? (sedation) • Gabapentine?

  18. Treatments for hepatobiliary pruritus.

  19. Naltrexone Mu-receptor opioid Antagonist • chronic pruritus of different origins • Post –burn Itch, • MF , • Drugs (starch) , • prurigonodularis, • Chronic urticaria, • Atopic dermatitis • 50-150 mg/d

  20. Topical Doxepin: • Doxepin is a topical tricyclic antidepressant used for the relife of pruritus & pain. • Antihistamine (both H1 & H2 receptors) with anticholinergic properties. • Indicated for moderate pruritus in patients with atopic & LSC & other forms of dermatitis & neuropathic pain (sometimes in combination with topical capsaicin) • Cream 5% , 4 times a day for 7-8 days • Side effects: burning, irritation, allergic C.D, drowsiness (in 20%)& sedation. • Contraindications: category B, sensitivity, narrow angel glaucoma, urinary retention, with MAO inhibitors

  21. Topical capsaicin: • A natural constituent of red chili peppers. • Antipruritic & analgesic by desensitizing nerve endings • Effects on the peripheral sensory nerve endings by depletion substance-pfrom C fibers. (substance-p mediates pain impulses from peripheral sensory neurons to the CNS) • With repeated use: prevent heat, pain & itch sensation. • Therapeutic effect is observed after 1 wk

  22. …Topical capsaicin • In intractable localized pruritus (prurigonodularis, brachioradial pruritus), uremic pruritus, superficial pain due to PHN , diabetic neuropathy, notalgia paresthetica, pruritus ani, psoriasis • Cream,gel, lotion 0.025- 0.075%, 4 times a day. • Side effects: category C , itching, burning, erythema (diminish with frequent use)

  23. …Others: • Gel pramoxine (1%): partial anesthesia (after few minutes) for 2-4 h effect (combination with 0.5-2.5% hydrocortisone as a lotion, foam, cream or ointment) • Side effect: very low sensitization potential • Camphor (0.25-0.5%): is a ketone with a local anesthetic effect & mild degrees of pruritus or burning. • Phenol: should not be used in pregnancy & infants less than 6 mo. • Menthol(0.025-0.5%): alcohol compound derived from mint (cooling effect as a result of its low boiling point) • Emollients: urea (10-20%), lactic acid (5-12%)

  24. 3-Iron deficiency anemia • Iron deficiency: generalized or localized (especially of the perianal or vulvar region) Treatment of choice : Iron supplement

  25. 4-Malignancy • The rate of malignancy in patients with pruritus of unknown origin is the same as normal population except for : • Hodgkin lymphoma & poly cythemiavera • - Obstruction of the biliary tree, particularly in palms & soles (carcinoma of the head of the pancreas or bile duct) • - “Central pruritus” in brain tumors or as a consequence of treatment (surgery, radiotherapy, chemotherapy) • - Tumors of the brain: localized pruritus of the nose

  26. Pruritus in Hodgkin lymphoma • 25% of Hodgkin's patients have pruritus. • Pruritus is Bizarre & Migratory. Severe, persistent generalized pruritus=recurrence of tumor or poor prognosis (B symptom) • - Due to release of histamine (from basophils), leukopeptidases or bradykinin, eosinophilia, occasionally hepatic involvement with lymphoma • Specific treatments for lymphoma. - Topical steroids - Oral mirtazapine (7.5-30 mg/d)

  27. Non –Hodgkin lymphoma: • Less prevalent( 2%), 10% of patients will suffer from pruritus, in the course of disease. - Treatment: INF-a systemic Leukemia: - Not common (usually generalized) Most commonly with CLL (in addition can develop exaggerated reactions to insect bites) • Paroxetine(selective serotonin reuptakeinhibitor in treatment of intractable pruritus such as advanced cancer)

  28. Pruritus in PCV • 30-50% of patients have pruritus. • Pruritus begins after exiting from water & lasts 30-60 minute(aquagenic pruritus) • The best treatments are: 1-Anti-PGs(aspirin 300mg qd TID) rapid relief it provides for 12-24 h 2- UVB or PUVA 3- IFN-a IM 4- Antihistamines H1 or H2 receptors Antiserotonins(cyproheptadine)?

  29. 5-Aquagenic pruritus • The clinic is the same as PCV. • 1/3 of patients have positive family history. • The treatment is the same as PCV.

  30. 6-Endocrine disorders (1-thyroid) Localized P:…candidiasis • A-hypothyroidism Generalized P:…xerosis Localized P:….candidiasis • B-hyperthyroidism Generalized P:…warmness of skin

  31. Endocrine (2-Diabetes mellitus) • generalized pruritus? scalp…neuropathy • Only localized.P genital…candidiasis.

  32. Endocrine(3-Postmenopausal syndrome) local ( in genital) or generalized with hot flushing. evokes Rubbing. Treatment with ethinyl estradiol (with anti Candida)

  33. 7-Immundeficiency(AIDS) • Pruritus is one of the most prevalent symptoms in both specific & non-specific dermatitis associated with HIV (Scabies, pediculosis, seborrhea, candidiasis,…) -Eosinophilic folliculitis

  34. 8-Prenancy • About 2-20% of pregnant women have Pruritus • The most common cause of pruritus is cholestasis. • Pruritus is one of the most common symptoms in both specific & non-specific dermatosis of pregnancy.

  35. 9-Neurological disorders • Brain tumors • Spinal cord lesions • Brain abscess • Multiple sclerosis • Neuropathies(Notalgia paresthetica) • etc

  36. 10-Psychologic disorders • Anxiety • Depression • Stress • Hysterics • Psychotic disorders parasitophobia,(treatment with pimozide, Risperidone, Olanzapine,….) • etc

  37. 11-Drugs • Mostly:Opiates,Phenothiazines,AspirinTolbutamide,Erythromycineesteolate, Anabolic hormones (esterogen,Progestron, Testosteron), Vit B-complex,… • Note:1-Every drug with idiosyncratic reaction can cause pruritus. 2-Drugs can cause pruritus months after the initiation of use.

  38. Evaluation of patients with pruritus of unknown origin • 1-Complete skin examination • 2-History(drugs,internal disorders , contact with animals, chemicals,..) • 3-Systemic review • 4-Physical examination (adenopathy,organomegally)

  39. ..Evaluation of patients with pruritus of unknown origin • 5-Screening tests (CBC, LFTs, RFTs,TFTs, Chest-X ray, stool occult blood) • 6-Other necessary tests • 7-Repeated history & Physical exam. • 8-Psychiatric assessment • 9-Periodic fallow up

  40. Winter pruritus: • Only in winter,but in any age. • Cause:xerosis due to overhydration &using strong detergents. • Clinic: xerosis & criss cross pattern especially on legs & arms. • Exacerbating of lesions after bathing. • Treatment: glycerin soap & emollient

  41. Senile pruritus: • 50% of elderly(>70Y) have senile .P. • In every seasons. • Cause & clinic is the same as winter's. • But other precipitating factors are: -Drugs like diuretics,.. -Hypothyroidism -Protein & Zinc deficiency,…

  42. Treatment of pruritus • No specific treatment A- General measures: restriction of scratching, emotional stress, intake of caffein,caffe, tea , choclate,coladrinks,alcohol. B-Topical treatments: -Ice compress -starch bath - menthol, phenol ,comphor lotions

  43. Continue - emollients - Anesthetics(only promoxin) - Doxepin cream - Capsaicin cream

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