The itchy patient

1. The itchy patient Maggie Kirkup SpR Dermatology Royal United Hospital Bath

2. Lambeth study1 55% population had a skin problem Approx 40% of these were itchy conditions 1. Rea et al Br J Prev Soc Med 1976; 30: 107-14

3. Descriptions of itching �local discomfort or irritation of the skin, prompting the sufferer to scratch or rub the affected area. It is the main symptom of skin disease� �a peculiar tingling or uneasy irritation of the skin that causes a desire to scratch the affected area�

4. Benefits of itching Scratching may combat ectoparasites Scratching can be pleasureable

5. �It feels as though every nerve ending in my body is attacking me intensely at my ankles, feet, lower legs, neck, under the breasts (even the nipples tingle). It's absolutely horrendous! My hands grow red as a beet and the itching nearly takes the skin off my hands as I scratch.� All Party Parliamentary Group on Skin. Report on the Enquiry into the Impact of Skin Diseases on People�s Lives. 2003

6. Pathophysiology Neurological Specific receptors and nerve fibres or shared with pain? Chemical mediators Include histamine, opiod peptides, serotonin Central Dysfunctional processing of sensory information

7. Approach to diagnosis of itching History including onset, duration, effect on sleep, previous skin disease, contacts, other medical problems, drugs, response to treatment so far Skin examination features of rash, signs of response to itching General examination

8. Signs of response to itching excoriation distress lichenification shiny nails weals nodules

9. Factors affecting presentation of itchy condition age other medical conditions/ ability to scratch site of itch self-control/ social setting/ distractions specific skin condition duration

10. Causes of itch skin disorders systemic disorders psychogenic habit (itch-scratch cycle) idiopathic / cause not yet found physiological?

11. Causes of itch skin disorders systemic disorders psychogenic habit idiopathic physiological?

12. Common generalised itchy skin disorders infestations: scabies eczemas xerosis/senescence psoriasis urticaria viral exanthems drug eruptions lichen planus pityriasis rosea bullous pemphigoid polymorphic light eruption insect bites

13. Less common skin complaints which itch dermatitis herpetiformis aquagenic pruritus some T cell lymphomas onchocerciasis etc etc

14. Localised itch Scalp: lice, seborrhoeic dermatitis Flexures: atopic/ seborrhoeic eczema Hands: eczemas, scabies, contact dermatitis Anogenital/ pruritus ani - think of threadworms, lichen sclerosis, lice, contact dermatitis Any area: discoid eczema, lichen simplex chronicus, contact dermatitis

15. Less common causes of localised itch brachioradial pruritus notalgia paraesthetica

16. Skin disorders which don�t (usually) itch psoriasis ? acne / folliculitis vasculitis/purpura erythema multiforme secondary syphilis

17. Causes of itch skin disorders systemic disorders psychogenic habit physiological?

18. Systemic causes of itch liver disease (cholestasis) chronic renal failure iron deficiency hypo and hyper thyroidism hypocalcaemia diabetes mellitus

19. Systemic causes of itch malignancies: lymphoma, PRV, leukaemias, myeloma pregnancy neurological drugs HIV AIDS: seb derm, cholestasis, scabies, candida, eosinophilic folliculitis

20. Psychogenic itch epidemic forms - hysteria delusional parasitosis habit - itch/scratch cycle pruritus ani diagnosis by exclusion

21. Screening investigations in itchy patients with no rash Full blood count Ferritin Renal function Liver function Thyroid function ? Chest X ray

22. Management of itching Treat the cause Treat the itch

23. Management of itching There is no specific drug for itch

24. Management of itching avoid provoking and aggravating factors temperature, humidity, bedding, clothing reduce damage from scratching clothing, bandaging, cut nails

25. Management of itching topical agents gadgets systemic agents psychological interventions keep looking for a cause

26. Topical agents emollients antihistamines* - doxepin (Xepin) unknown mechanism crotamiton (Eurax) calamine counter-irritant capsaicin, menthol local anaesthetics* * Risk sensitization

27. Management of itching topical agents gadgets systemic agents psychological interventions

29. Management of itching topical agents gadgets systemic agents psychological interventions

30. Systemic agents Antihistamines urticaria, dermographism, atopic eczema Opiod antagaonists cholestasis, notalgia paraesthetica Ondansetron cholestasis Cholestyramine cholestasis

31. Systemic agents Antidepressants, anxiolytics some psychogenic problems Thalidomide Nodular prurigo Phototherapy uraemic pruritus, PRV,aquagenic pruritus

32. Management of itching topical agents gadgets systemic agents psychological interventions

33. Psychological and alternative interventions Biofeedback Behavioural therapy* Relaxation techniques Acupuncture Hypnotherapy Homeopathy Self-help groups *Melin I et al Behavioural treatment of scratching in patients with atopic dermatitis. Brit J Dermatol 1986; 115: 467-74

34. Summary Itching can be caused by skin disease, systemic disease, psychogenic factors or idiopathic Management and investigation need to be tailored to the patient�s condition and circumstances Keep looking for a cause if no rash evident