Managing the Patient with Chronic Itch Dr Nicky Jackson

Differential Diagnosis

� Rash or No Rash

Differential Diagnosis- Rash

� Nodular Prurigo �  Inflammatory (Eczema/ Psoriasis/ LP) � Urticaria �  Scabies � Tinea � Bullous Pemphigoid � Dermatitis Herpetiformis � Cutaneous Lymphoma

Differential Diagnosis – No Rash

�  Systemic disease (Thyroid, low Fe, uraemia, polycythaemia, malignancy)

� Psychogenic

� Dementia senile pruritis

Prurigo

Prurigo �  Very common �  Insect bites can precipitate �  Very strong urge to itch �  Topical steroids/ emollients/ soap substitutes �  Sedative antihistamines eg hydroxyzine � Occlusive bandages/ dressings �  Refer ? Biopsy (exclude DH BP) � UVA/ UVB (thalidamide)

Inflammatory Skin Conditions

Inflammatory Skin Conditions � Diagnose History/ Examination (Eczema,

Psoriasis, Lichen Planus)

� Patch Testing

� Xerosis very common in elderly

�  (New presentation eczema from Sub Saharan Africa HIV)

Urticaria

� Chronic > 6 weeks (CIU) � Physical urticarias , dermographism,

delayed pressure cholinergic (cold/ heat rare)

� Urticarial vasculitis lesions > 48hrs (biopsy 1 case per cons clinic/ year)

Scabies

� Burrows hands/ feet (dermatoscope) �  Family contacts �  Itch worse at night �  If lots of itch but not much to see

consider scabies � Average 10-12 mites � Noweigan Crusted Scabies

Cutaneous lymphoma

�  Suspicion � Refer needs biopsy

Immunobullous Disorders

� Pemphigoid (indirect/ direct immunofluoresence) IgG dermal/ epidermal junction

� Dermatitis Herpetiformis

� Direct / indirect IMF- IgA sub epidermal. Positive coeliac serology, villous atrophy

Bullous Pemphigoid

Dermatitis Herpetiformis

Tinea

� Very common �  Send scrapings/ clippings � Consider if unilateral itchy rash

No Rash – Pruritis Screen

� Tests 1st Line- TFTs Lfts U/Es FBC Ferritin Gluc CRP

� 2nd line- CXR serum electrophoresis autoantibodies Stool sample (parasites) HIV biopsy

Medication

� Common – need to stop 6 weeks �  Statins � ACE – change to sartan � Opioids � Aspirin � Amiodarone � Allopurinol

Types of Itch

�  Sudden onset - unlikely to be systemic � Hands/ feet – hepatobiliary � Aquagenic – Polycythaemia, asteototic

eczema � 30-40 yr Female raised crp and itch –

Primary Biliary Cirrhosis � Chronic itch, wt loss, night sweats

consider malignancy

Management �  Emollients including dermacool �  Soap substitutes � Keep nails short and filed �  Encourage rub with palms/ not scratch with

fingernails �  Pruritis Screen � Medication review, trial stopping 6 weeks � Mild/ moderate steroids �  Sedating antihistamines eg hydroxyzine �  Refer UVB