Evaluation of pruritus

recurrent dermatitis in areas of exposure to potential allergens such as skincare products or wool and lipid solvents (many patients have a history of milk allergy during infancy, and most also have other atopic disorders such as hay fever, atopic asthma, or a family history of atopic diseases)[50]Eichenfield LF, Tom WL, Chamlin SL, et al; American Academy of Dermatology. Guidelines of care for the management of atopic dermatitis. Part 1: Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014;70:338-351. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4410183 http://www.ncbi.nlm.nih.gov/pubmed/24290431?tool=bestpractice.com

patients present with typical morphology and distribution of skin lesions: facial and extensor in infants and children, flexural lichenification in adolescents and adults; patients may present a wide range of other findings defined as minor criteria of atopic dermatitis[51]Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol. 1980;(suppl 92):44-47.

sudden appearance of wheals with concomitant pruritus; patients can sometimes identify causative factors (e.g., cold, heat, water, food, drugs); detailed food diaries and in-depth drug reviews are typical starting points for diagnosis; list of possible factors is very long, so all patients should be thoroughly investigated

patients present typically with pruritic wheals; sometimes angioedema of lips, tongue, eyelids, or distal parts of extremities may be seen

history of traveling, especially to wet regions

presence of dome-shaped urticarial papules, sometimes with a dot at summit of papule that represents site of the bite; lesions usually occur on unclothed areas of the skin; this is a short-lived reaction, but in some patients lesions may persist for weeks or months; similar symptoms are sometimes present in other family members

perianal pruritus

erosions and secondary infections in perianal area

intense pruritus, especially at night in bed[57]Sunderkötter C, Mayser P, Folster-Holst R, et al. Scabies. J Dtsch Dermatol Ges. 2007;5:424-430. http://www.ncbi.nlm.nih.gov/pubmed/17451390?tool=bestpractice.com

sites of predilection are the interdigital spaces, anterior axillary folds, nipples, umbilicus, elbows, and genitalia (especially scrotum); face and interscapular region are very rarely involved; the most diagnostic finding is an intact tunnel with a tiny dark dot (mite) at the end

nonspecific; sometimes a history of drug intake (e.g., gold salts) or hepatitis that can provoke lichen planus; frequently associated with intense pruritus

presence of small, smooth, violaceous, shiny, flat papules; lesions frequently involve inner aspects of wrists and back of the feet; Koebner phenomenon (lesions on areas or along lines of skin trauma) may be present; sometimes cutaneous lesions are associated with mucosal changes (lacy network on buccal mucosa or painful erosions); some patients may also have nail abnormalities manifesting mainly as longitudinal ridging

positive family history of psoriasis

primary lesion of psoriasis is a small, red, sharply demarcated papule covered with silvery scale; psoriatic papules may coalesce to form larger plaques; numerous clinical variants of psoriasis have been described; lesions are usually found on scalp, extensor areas (elbows, knees), and in sacroiliac area; nails may be involved (pitting, onycholysis, "oil spots")

no specific features of skin dryness; diagnosis is based on skin appearance; usually older patients; may also be a nonspecific symptom of different skin or systemic diseases (e.g., atopic dermatitis, malignancies, chronic renal failure); it is important to exclude these possible conditions, which may be responsible for secondary skin dryness

dry, scaly skin

history of chronic liver disease or alcohol misuse, or hepatotoxic drug intake; the pruritus complicating liver diseases tends to be generalized and is not adequately relieved by scratching; itching commonly starts on palms and soles; consider cholestasis of pregnancy if patient is pregnant

no primary rash, sometimes secondary scratch lesions (excoriations, prurigo nodularis); pruritus is usually connected with cholestasis (jaundice) but may also be present in noncholestatic liver diseases

history of chronic renal disease; pruritus may be present before and more commonly during hemodialysis treatment; itching may be generalized or localized[15]Manenti L, Tansinda P, Vaglio A. Uraemic pruritus: clinical characteristics, pathophysiology and treatment. Drugs. 2009;69:251-263. http://www.ncbi.nlm.nih.gov/pubmed/19275270?tool=bestpractice.com

many patients have skin xerosis;[61]Szepietowski JC, Reich A, Schwartz RA. Uraemic xerosis. Nephrol Dial Transplant. 2004;19:2709-2712. http://ndt.oxfordjournals.org/content/19/11/2709.full http://www.ncbi.nlm.nih.gov/pubmed/15328388?tool=bestpractice.com scratch lesions such as prurigo are common

recent history of herpes zoster infection; localized itch affects >40% of affected patients;[69]Oaklander AL, Bowsher D, Galer B, et al. Herpes zoster itch: preliminary epidemiologic data. J Pain. 2003;4:338-343. http://www.ncbi.nlm.nih.gov/pubmed/14622691?tool=bestpractice.com may occur at the same time and location as postherpetic neuralgia; typical symptoms of herpes zoster infection (i.e., dermatomal pain followed by a rash in the affected area)

rash in dermatomal distribution

itching occurring during every depression episode and resolving spontaneously with improvement of the depression

patients appear sad, tense, slow in movement or agitated, voicing a lack of pleasure in life or hopelessness, poor sleep, low energy, changed appetite (usually decreased, but can overeat), poor concentration and memory; significant psychomotor agitation

itching is not limited to a specific area and has no specific characteristics; it is frequently masked by various other symptoms of the disorder[26]Yosipovitch G, Greaves MW, Fleischer AB, et al. Itch: basic mechanisms and therapy. New York, Basel: Marcel Dekker; 2004.[71]Mazeh D, Melamed Y, Cholostoy A, et al. Itching in the psychiatric ward. Acta Derm Venereol. 2008;88:128-131. http://www.ncbi.nlm.nih.gov/pubmed/18311438?tool=bestpractice.com

patients exhibit delusional thinking, hallucinations, thought and behavioral disorganization, some degree of impairment in carrying out roles of daily living

recent history of intake of a new drug known to induce pruritus; pruritus usually disappears on ceasing treatment but may sometimes appear as pruritic crises triggered by friction, bathing in warm water, or physical stress

localized or generalized pruritus, sometimes with typical location (e.g., scratching of nose and perinasal area in opioid-induced pruritus)

history of burn; may interfere with sleep and activities of daily living[31]Bell PL, Gabriel V. Evidence based review for the treatment of post-burn pruritus. J Burn Care Res. 2009;30:55-61. http://www.ncbi.nlm.nih.gov/pubmed/19060768?tool=bestpractice.com [32]Goutos I, Eldardiri M, Khan AA, et al. Comparative evaluation of antipruritic protocols in acute burns: the emerging value of gabapentin in the treatment of burns pruritus. J Burn Care Res. 2010;31:57-63. http://www.ncbi.nlm.nih.gov/pubmed/20061838?tool=bestpractice.com

burn noted; additional tissue damage from scratching may be noted[31]Bell PL, Gabriel V. Evidence based review for the treatment of post-burn pruritus. J Burn Care Res. 2009;30:55-61. http://www.ncbi.nlm.nih.gov/pubmed/19060768?tool=bestpractice.com

can be asymptomatic; nonspecific gastrointestinal symptoms include anorexia, dyspepsia, nausea, vomiting, diarrhea, constipation, abdominal distension; symptoms of visceral larva migrans: abdominal pain in peritonitis and small bowel obstruction; fever, cough, wheezing, dyspnea, hemoptysis in pneumonia; fatigue in nutritional deficiency

signs of visceral larva migrans: rebound tenderness and guarding in peritonitis; abdominal distension and tenderness, reduced or absent bowel sounds in small bowel obstruction; hepatomegaly, right upper quadrant tenderness, jaundice in hepatobiliary ascariasis; splenomegaly; hypoxia, tachypnea, rhonchi, rales, retractions in pneumonia; brittle hair, cracked skin, edema, conjunctival pallor in nutritional deficiency

history of traveling to endemic regions (Mexico, Central America, western South America, South Asia, and western and southern Africa); right upper quadrant (RUQ) abdominal pain, fever, cough in amebic liver abscess

can be asymptomatic; mild diarrhea to dysentery with blood and mucus in the stool; RUQ tenderness, jaundice in amebic liver abscess; altered mental status or limb weakness in amebic brain abscess

exposure to soil contaminated with animal feces

wreath-like or road-like linear, erythematous, highly pruritic tunnels in the skin

gastrointestinal symptoms are the most prevalent: nausea and vomiting; early satiety; bloating; substernal burning; egg-smelling halitosis; abdominal cramps; explosive, watery diarrhea; foul flatus; and fever

usually unremarkable

history of traveling to endemic areas, skin exposure to contaminated freshwater, abdominal pain, hematuria, hematemesis

acute phase: allergic febrile reaction with urticaria, arthritis, and fever

history of consuming undercooked meat or seafood or contaminated water; inhabitant of endemic region or work on farm; intestinal infection (e.g., with Hymenolepis nana, Diphyllobothrium latum, Taenia saginata) can be asymptomatic, although may present with vague intestinal symptoms including abdominal pain, hunger pain, sore tongue, sore gums, loss of appetite, increased appetite, weight loss, bloating, constipation, diarrhea, a feeling of "something moving inside," and/or nausea;[53]Khalil HM, el Shimi S, Sarwat MA, et al. Recent study of Hymenolepis nana infection in Egyptian children. J Egypt Soc Parasitol. 1991;21:293-300. http://www.ncbi.nlm.nih.gov/pubmed/2033304?tool=bestpractice.com [54]Wittner M, Tanowitz HB, White AC. Taenia and other tapeworms. In: Guerrant RL, Walker DH, Weller PF, eds. Tropical infectious diseases: principles, pathogens & practice. 1st ed. Oxford, UK: Churchill Livingstone; 2005:1327-1340. patient may describe worm segments in stool; individuals infected with Taenia solium may be asymptomatic or may present with vague intestinal symptoms as above, or with anxiety, headaches, dizziness, urticaria; patients with H nana may present with an itchy rash;[55]Di Lernia V, Ricci C, Albertini G. Skin eruption associated with Hymenolepis nana infection. Int J Dermatol. 2004;43:357-359. http://www.ncbi.nlm.nih.gov/pubmed/15117366?tool=bestpractice.com may present with urticaria in leaking echinococcal cyst

usually unremarkable for those harboring intestinal tapeworm; patients with H nana may have macular-papular skin eruptions;[55]Di Lernia V, Ricci C, Albertini G. Skin eruption associated with Hymenolepis nana infection. Int J Dermatol. 2004;43:357-359. http://www.ncbi.nlm.nih.gov/pubmed/15117366?tool=bestpractice.com neurocysticercosis may reveal neurologic defects corresponding to central nervous cysts; extraparenchymal neurocysticercosis may present with increased intracranial pressure and hydrocephalus, and tends to be more severe in its presentation;[56]Cuetter AC, Garcia-Bobadilla J, Guerra LG, et al. Neurocysticercosis: focus on intraventricular disease. Clin Infect Dis. 1997;24:157-164. http://cid.oxfordjournals.org/content/24/2/157.long http://www.ncbi.nlm.nih.gov/pubmed/9114141?tool=bestpractice.com presentation varies according to size, location, and condition of the cyst

consumption of raw or undercooked meat; sick contacts; may present with myalgia and myositis, fever, nausea and vomiting, abdominal pain, diarrhea, rash, pruritus, sweating, sensation of crawling insects beneath the skin, oliguria, with severe muscle involvement: dysphagia, dysphonia, dyspnea, paralysis-like state; headache

periorbital/facial edema, conjunctivitis and subconjunctival hemorrhages; subungual and retinal splinter hemorrhages, other ocular features, hepatomegaly, maculopapular rash

history of gluten intolerance; presence of other autoimmune diseases; exacerbation of symptoms due to iodide exposure (e.g., after eating shellfish)

presence of pruritic erythematous papules, tiny vesicles, and small blisters over knees, elbows, shoulders, scalp, and buttocks

sometimes a history of drug intake (e.g., ACE inhibitors, diuretics); blistering eruptions occur mainly in older people

tense blisters on the erythematous background with concomitant pruritus; initial lesions may be urticarial and very pruritic; mucosal lesions can be seen in 10% to 20% of patients[58]Yancey KB, Egan CA. Pemphigoid: clinical, histologic, immunopathologic, and therapeutic considerations. JAMA. 2000;284:350-356. http://www.ncbi.nlm.nih.gov/pubmed/10891967?tool=bestpractice.com [59]Alonso-Llamazares J, Rogers RS 3rd, Oursler JR, et al. Bullous pemphigoid presenting as generalized pruritus: observations in six patients. Int J Dermatol. 1998;37:508-514. http://www.ncbi.nlm.nih.gov/pubmed/9679691?tool=bestpractice.com [60]Bakker CV, Terra JB, Pas HH, et al. Bullous pemphigoid as pruritus in the elderly: a common presentation. JAMA Dermatol. 2013;149:950-953. http://www.ncbi.nlm.nih.gov/pubmed/23804286?tool=bestpractice.com

sometimes a history of bleeding, otherwise nonspecific

signs in addition to pruritus: glossitis, angular cheilitis, pale mucous membranes

history of type 1 or type 2 diabetes; risk factors include prolonged duration of diabetes (e.g., >10 years), older age (e.g., >70 years), tall stature, and hyperglycemia; may be asymptomatic; symptoms of peripheral neuropathy include pain, dysesthesias, numbness, weakness is less common; may be associated with features of autonomic neuropathy (orthostatic hypotension, gastroparesis, esophageal dysfunction, diarrhea, fecal incontinence, bladder dysfunction, and erectile dysfunction)

loss of vibration sense and light touch (may show stocking and glove distribution), reduced ankle reflexes, injuries without pain (especially feet)

prolonged generalized pruritus that often precedes diagnosis

enlargement of peripheral lymph nodes, fever, malaise, skin xerosis

venous or arterial thrombosis; pricking-type itch persisting for hours after a hot shower or bath;[64]Diehn F, Tefferi A. Pruritus in polycythaemia vera: prevalence, laboratory correlates and management. Br J Haematol. 2001;115:619-621. http://www.ncbi.nlm.nih.gov/pubmed/11736946?tool=bestpractice.com [65]Gangat N, Strand JJ, Lasho TL, et al. Pruritus in polycythemia vera is associated with a lower risk of arterial thrombosis. Am J Hematol. 2008;83:451-453. http://www.ncbi.nlm.nih.gov/pubmed/18257107?tool=bestpractice.com some patients may also have aquagenic pruritus (i.e., intense itching sensation that develops immediately after contact with water at any temperature), headache, dizziness, and acral paresthesias[66]Saini KS, Patnaik MM, Tefferi A. Polycythemia vera-associated pruritus and its management. Eur J Clin Invest. 2010;40:828-834. http://www.ncbi.nlm.nih.gov/pubmed/20597963?tool=bestpractice.com

signs of thrombosis (e.g., cyanotic face skin color, often plethoric with blue-red tone; often, darkened oral mucous membranes)

history of drug misuse (especially intravenous); multiple sexual partners; travelers from endemic regions, especially those with a history of transfusion or unprotected sexual intercourse

features typical of one of the commonly associated dermatologic conditions such as HIV-associated eosinophilic folliculitis, pruritic papular eruption, xerosis, seborrheic dermatitis, psoriasis, scabies, superficial fungal infections, drug eruptions, urticaria, photosensitivity reactions

generalized pruritus develops in 4% to 11% of patients with hyperthyroidism;[67]Caravati CM Jr, Richardson DR, Wood BT, et al. Cutaneous manifestations of hyperthyroidism. South Med J. 1969;62:1127-1130. http://www.ncbi.nlm.nih.gov/pubmed/5809986?tool=bestpractice.com pruritus also occurs with hypothyroidism, mainly due to skin xerosis; symptoms of hypothyroidism include weight gain, cold intolerance, fatigue, constipation, dry skin; symptoms of hyperthyroidism include anxiety, heat intolerance, palpitations, weight loss, weakness, eye problems, diarrhea, tremor, moist skin

hypothyroidism: bradycardia, waxy and dry skin, myxedema; hyperthyroidism: tachycardia, thyroid enlargement, tremor, exophthalmos, moist and smooth skin

generalized pruritus may be the first and only symptom of various malignancies (e.g., carcinoid; cancers of the breast, stomach, lungs, vulva, prostate, colon, rectum; leukemias; lymphomas); symptoms of underlying malignancy may also be present; sometimes pruritus may occur in the late stages of cancer disease accompanying cachexia and requiring palliative treatment[68]Weisshaar E, Weiss M, Mettang T, et al. Paraneoplastic itch: an expert position statement of the Special Interest Group (SIG) of the International Forum on the Study of Itch (IFSI). Acta Derm Venereol. 2015;95:261-265. http://www.ncbi.nlm.nih.gov/pubmed/25179683?tool=bestpractice.com

generalized pruritus, sometimes associated with xerosis

history of symmetric pruritus in the elbow region, over the proximal muscle-tendon attachments of brachioradial muscle; pruritus sometimes extends across the back and occasionally to the chest; patients frequently report exacerbation after sun exposure[48]Mirzoyev SA, Davis MD. Brachioradial pruritus: Mayo Clinic experience over the past decade. Br J Dermatol. 2013;169:1007-1015. http://www.ncbi.nlm.nih.gov/pubmed/23796379?tool=bestpractice.com

usually no visible abnormalities of skin; secondary changes (e.g., lichenification and/or hyperpigmentation) due to chronic rubbing or scratching may sometimes be present

localized, usually unilateral itching on back near scapula in T2-T6 dermatomes; pruritus may be accompanied by other symptoms such as burning, tingling, numbness, or formication; notalgia paresthetica may also be a neurologic symptom in patients with multiple endocrine neoplasia 2A (medullary thyroid carcinoma, pheochromocytoma, parathyroid hyperplasia) that must be excluded[49]Ellis C. Notalgia paresthetica: the unreachable itch. Dermatol Pract Concept. 2013;3:3-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663387 http://www.ncbi.nlm.nih.gov/pubmed/23785628?tool=bestpractice.com [70]Chabre O, Labat F, Pinel N, et al. Cutaneous lesion associated with multiple endocrine neoplasia type 2A: lichen amyloidosis or notalgia paresthetica? Henry Ford Hosp Med J. 1992;40:245-248. http://www.ncbi.nlm.nih.gov/pubmed/1362414?tool=bestpractice.com

usually no visible skin abnormalities, sometimes secondary changes (e.g., lichenification and/or hyperpigmentation) due to chronic rubbing or scratching may be present

localized pruritus (e.g., affecting nose and face); patient may present with other neurologic symptoms/deficits indicating brain tumor: for example, symptoms of raised intracranial pressure (headache, altered mental status, nausea and/or vomiting)

focal neurologic deficits according to tumor location; gait abnormality; papilledema in raised intracranial pressure

history of unilateral neurogenic pruritus; other more common symptoms of stroke include limb and/or facial weakness, paresthesias or numbness, speech difficulty, headache, visual loss or double vision, confusion, dizziness, vertigo, nausea, neck or facial pain, impaired coordination

focal neurologic deficits according to site of stroke may include hemiplegia, motor hemiparesis, sensory hemiparesis, dysphasia or aphasia, dysarthria, ataxia

paroxysmal, symmetric, segmental itching that can last from several seconds to few minutes; itching attacks that often awaken patient from sleep; episodes may be spontaneous or triggered by a bath or sudden movement[26]Yosipovitch G, Greaves MW, Fleischer AB, et al. Itch: basic mechanisms and therapy. New York, Basel: Marcel Dekker; 2004.

witnessed itching and excoriations may be present in any part of the body

compulsory criteria: localized or generalized, chronic (>6 weeks) pruritus without primary skin lesions and other somatic cause; additional criteria (3 of 7 have to be present): chronologic relationship of pruritus with 1 or several life events that could have psychological repercussions, variations in the intensity associated with stress, nocturnal variations, predominance during rest or inaction, associated psychological disorders, pruritus that could be improved by psychotropic drugs, pruritus that could be improved by psychotherapies[72]Misery L, Alexandre S, Dutray S, et al. Functional itch disorder or psychogenic pruritus: suggested diagnosis criteria from the French Psychodermatology Group. Acta Derm Venereol. 2007;87:341-344. http://www.ncbi.nlm.nih.gov/pubmed/17598038?tool=bestpractice.com

no physical signs of skin diseases and other disorders that may be responsible for pruritus

delusions of parasitosis

no physical signs of skin disease and parasitosis; psychiatric consultation may be warranted, but patient may refuse[73]Reich A, Kwiatkowska D, Pacan P. Delusions of Parasitosis: An Update. Dermatol Ther (Heidelb). 2019 Dec;9(4):631-638. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6828902 http://www.ncbi.nlm.nih.gov/pubmed/31520344?tool=bestpractice.com

urticaria, pruritus, migrating worm may be seen under the skin

dermatitis and nodules; Loa loa infestation more likely to present with visual defects and signs of eye infection

history of migration from endemic part of world; abdominal pain, altered bowel habit, and weight loss are common symptoms; patient may complain of pruritus

dermatitis, larva currens; if hyperinfection there may be signs of sepsis