Essential dermatology for gps
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Essential Dermatology for GPs. The Itchy Patient Lucy Scriven. Itching may be due to an underlying skin condition Eczemas Scabies, lice, threadworms Psoriasis (sometimes) Insect bites Exanthems Lichen planus Nodular prurigo Bullous pemphigoid Polymorphic light eruption.

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Essential Dermatology for GPs

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Essential dermatology for gps

Essential Dermatology for GPs

The Itchy Patient

Lucy Scriven


Essential dermatology for gps

  • Itching may be due to an underlying skin condition

    • Eczemas

    • Scabies, lice, threadworms

    • Psoriasis (sometimes)

    • Insect bites

    • Exanthems

    • Lichen planus

    • Nodular prurigo

    • Bullous pemphigoid

    • Polymorphic light eruption


What s this

What’s this?

  • Pompholyx


Essential dermatology for gps

  • PLE


Essential dermatology for gps

  • Bullous pemphigoid


Essential dermatology for gps

  • Eczema


Essential dermatology for gps

  • Lichen planus


Essential dermatology for gps

  • Psoriasis


Essential dermatology for gps

  • Scabies


Essential dermatology for gps

  • Papular urticaria


What if they are just itchy

What if they are just itchy?

Pruritus = Itchy skin in the absence of any obvious dermatological condition

Generalised Pruritus

Localised Pruritus

Brachioradial pruritus

Notalgia paraesthetica

  • Medications

  • Dermatological conditions with subtle signs

  • Systemic disease

  • Psychogenic

  • Aquagenicpruritus

  • Idiopathic


Essential dermatology for gps

  • Up to 50% of pts will have no clear cause – idiopathic pruritus

  • This should be a diagnosis of exclusion!

  • So – we need a logical approach to try to ascertain a cause.......


Essential dermatology for gps

STEP 1: TAKE A CAREFUL HISTORY

  • Onset, duration, pattern, effect on sleep, past history of skin disease, contacts, response to treatments so far

  • Medications

    • Opioids, Statins, ACEI, Digoxin

    • Need to discontinue suspected drug for a few weeks if possible

  • Systemic disease

    • Liver disease, renal failure, haematological disorders, thyroid disease, paraneoplastic


Essential dermatology for gps

  • Localised Pruritus – 2 conditions which cause localised areas of itching / burning

    • Brachioradial pruritus - around elbow and extensor surface of forearm

    • Notalgia paraesthetica – mid-scapular area

    • Consider capsaicin cream

      thinly od increased to

      maximum qds over 2wks.

      Treat for 8 wks

      Or try gabapentin or low

      dose amitriptyline.


Essential dermatology for gps

  • Aquagenic pruritus

    • Patients complain of intense pricking itch on contact with water or change of skin temperature

    • Do not develop a rash

    • Responds poorly to antihistamines

    • May respond to phototherapy


Essential dermatology for gps

STEP 2: EXAMINE THE PATIENT CLOSELY

  • Dry skin / asteototic eczema

    • Common cause, especially in the elderly in winter

    • Signs may be subtle

    • FEEL the skin!

    • Look closely for fine scale

  • Excoriations

  • Bruising

  • Lichen simplex chronicus


Essential dermatology for gps

  • Asteototic eczema


Essential dermatology for gps

  • Excoriations


Essential dermatology for gps

  • ‘Butterfly’ distribution


Essential dermatology for gps

  • Lichen simplex chronicus


Essential dermatology for gps

  • Dermographic urticaria

    • Should be reproducible


Essential dermatology for gps

STEP 3 - ? SYSTEMIC DISEASE

  • Liver disease, renal failure, haematological disorders (e.g. Iron deficiency anaemia, polycythaemia, Hodgkin’s lymphoma), thyroid disease, paraneoplastic phenomena, pregnancy

  • Thorough history and examination to include checking for enlarged lymph nodes and hepatosplenomegaly


Essential dermatology for gps

  • Screening investigations in pruritus

    • Full blood count

    • Ferritin

    • CRP

    • Routine biochemistry (U&E, LFT, bone, glucose)

    • Thyroid function

    • Antimitochondrial antibody (1 biliary cirrhosis)

    • Urinalysis

    • Chest X ray

    • Consider immunoglobulins and plasma electrophoresis in older pts


Essential dermatology for gps

STEP 4 - ? PSYCHOGENIC

  • Anxiety / depression can cause or be caused by pruritus, esp in older pts

  • Delusions of parasitosis

    • Patient is convinced that a parasite / infestation is living in their skin

    • May bring inorganic matter to the consultation

    • Excoriations often seen but nothing else – no burrows, no urticated papules


Essential dermatology for gps

  • Idiopathic Pruritus

    • No identifiable cause found in up to 50% pts

    • Can cause persistent and widespread itching and often extensive excoriation

    • Common in 7th decade and beyond


Management

Management

  • Treat any underlying cause

  • Provide a patient information leaflet

  • General measures

    • Liberal emollients if at all dry – keep in fridge

    • Sedating antihistamines e.g. Hydroxyzine 25-50mg nocte +/- 10mg tds through the day if required. Use periodically as tolerance may develop

    • Topical agents e.g. 1 or 2% menthol in Aqueous cream, Eurax cream, Balneum Plus / Dermol

    • Phototherapy may help in recalcitrant cases


Essential dermatology for gps

  • Manage any features of anxiety or depression

    • Consider low dose amitriptyline (25-75mg nocte)

  • If associated with hepatic or renal disease or malignancy

    • Can be difficult to treat

    • Naltrexone and rifampicin have been reported as helpful in renal disease

    • Cholestyramine can be effective if secondary to liver disease

  • Avoid aggravating factors

  • Reduce damage from scratching


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