Pruritus (itch)

Pruritus and itch are synonymous terms. Pruritus is defined as an unpleasant sensation on the skin that provokes the desire to rub or scratch the area to obtain relief. Pruritus can cause discomfort and frustration; in severe cases it can lead to disturbed sleep, anxiety and depression. Constant scratching to obtain relief can damage the skin (excoriation, lichenification) and reduce its effectiveness as a major protective barrier.

Scratching due to generalised pruritus

Excoriations

Bruising from itch due to primary biliary cirrhosis

Renal pruritus

What causes pruritus?

There are numerous causes of pruritus. Basically they can be classified under 5 main headings as follows:

Localised pruritus

• Pruritus that is confined to a certain part of the body

Some causes of localised pruritus
Scalp	Seborrhoeic dermatitis Head lice
Back	Notalgia paraesthetica Grover's disease
Arm	Brachioradial pruritus
Hands	Pompholyx Hand dermatitis
Groin	Pruritus vulvae Vulvovaginal candida Vulvar and vaginal problems in prepubertal females Lichen sclerosus
Anus	Pruritus ani
Legs	Gravitational eczema
Feet	Tinea pedis

Systemic causes

• Pruritus caused by systemic disease

Some systemic disorders that cause pruritus
Kidney disease	Chronic renal failure
Liver disease	Intrahepatic and extrahepatic biliary obstruction
Endocrine/metabolic	Diabetes Hyperthyroidism Hypoparathyroidism Myxoedema
Blood	Iron deficiency anaemia Polycythaemia Lymphatic leukaemia Hodgkin's disease
Nervous system	Neuropathic pruritus Neurotic excoriations Delusions of parasitosis

Skin disease

Pruritus is often a symptom of many skin diseases. Some of these include the following:

• Allergic contact dermatitis
• Dry skin
• Prurigo nodularis
• Urticaria
• Psoriasis
• Atopic dermatitis
• Folliculitis
• Dermatitis herpetiformis
• Lichen simplex
• Lichen planus
• Bullous pemphigoid
• Lice
• Scabies
• Miliaria
• Sunburn
• Pityriasis rosea
• Mycosis fungoides

Exposure-related

Pruritus occurring as a result of exposure to certain external factors

• Allergens or irritants
• Physical urticaria
• Aquagenic pruritus
• Insects and infestations
• Medications (topical or systemic) e.g. opioids, aspirin

Hormonal

2% of pregnant women have pruritus without any obvious dermatological cause. In some cases the itch is due to cholestasis (pooling of bile in the gall bladder and liver). It usually occurs in the 3rd trimester and is relieved after giving birth.

Itch is a common symptom of menopause.

What treatment is available?

The management of pruritus relies heavily on establishing the cause and then either removing or treating the cause to prevent further itching. In many cases, tests are necessary to determine the cause; while these are in progress, treatment to provide symptomatic relief of pruritus may be given.

Topical treatment may include:

• Cool the skin with wet dressings or a tepid shower
• Calamine lotion: avoid on dry skin and limit use to a few days (contains phenol)
• Menthol/camphor lotion: gives a chilling sensation
• Regular use of emollients, especially if skin is dry
• Mild topical corticosteroids for short periods

Topical antihistamines should not be used as they may sensitise the skin and result in allergic contact dermatitis.

If pruritus is severe and sleep is disturbed, then treatment with oral medication may be necessary. Some drugs may help to relieve the itch whilst others are given solely for their sedative effects.

• Aspirin: effective if kinin or prostaglandin mediated pruritus (but may aggravate itch in some patients).
• Doxepin or amitriptyline: tricyclic antidepressants with effective antipruritic action. Tetracyclic antidepressants such as mirtazepine and selective serotonin reuptake inhibitors (paroxetine, sertraline, fluoxetine) may help some patients with severe itch.
• Antihistamines: the non-sedating antihistamine cetirizine has antipruritic action. Sedating antihistamines may be used for their sedative effects.
• Anti-epileptic drugs such as gabapentin and pregabalin may also be of benefit to some patients.
• Thalidomide has been very successful in treating nodular prurigo and chronic pruritus of various kinds.
• Opioid antagonists such as butorphanol intranasal spray and naltrexone tablets have been effective in patients suffering from intractable pruritus.

Other measures that can be useful in preventing pruritus include avoiding precipitating factors such as rough clothing or fabrics, overheating, and vasodilators if they provoke itching (e.g. caffeine, alcohol, spices). Fingernails should be kept short and clean. If the urge to scratch is irresistible then rub the area with your palm.