Pruritis without Rash

Pruritus, or itching, is the most common dermatologic complaint. When pruritus occurs without cutaneous findings, a thorough history, physical exam, and laboratory tests must be obtained to rule out a systemic disease as a cause of pruritus. The prevalence of an underlying systemic disease in a pruritic patient is 10–50%.

Differential Diagnosis

• Hepatobiliary disorders
  –Cholestasis of pregnancy: Pruritus is most severe in third trimester, ceases after delivery
  –Primary biliary cirrhosis: Increased anti-mitochondrial antibodies
  –Biliary obstruction: Pruritus not a presenting symptom
• Endocrine disorders
  –Hypo- and hyperthyroidism

• Hematopoietic disorders
  –Polycythemia vera: Pruritus classic after emerging from bath, described as severe and prickling
  –Hodgkin's lymphoma: Pruritus may present 5 years before diagnosis; pruritus portends a poor prognosis
  –Iron deficiency anemia
• Chronic renal failure: pruritus begins 6 months after start of dialysis, affects up to 75% of patients during or immediately after dialysis
• Malignancies: Adenocarcinoma, squamous cell carcinomas
• HIV: Increasing frequency with disease progression
• Psychogenic states: May have underlying personality disorder such as OCD
• Senescence: Elderly pruritus very common
• Drug reactions
• Less common etiologies (“zebras”) include multiple myeloma, carcinoid syndrome, Waldenström's macroglobulinemia, parasitic infections (e.g., hookworm, onchocerciasis, ascariasis, trichinosis), hepatitis B and C, diabetes mellitus (results in perianal pruritus)

Workup and Diagnosis

• History and physical examination
  –A focused history including past medical history, social history, family history, and sexual history is important
  –A complete review of systems may identify underlying disease (e.g., change in bowel habits with colon cancer, cold intolerance with hypothyroidism, right upper quadrant pain with hepatic disease)
  –Complete physical examination is necessary including stool exam for occult blood, and Pap smear and pelvic examination
  –Include a full body skin exam to confirm that there are no cutaneous rashes or lesions
• Initial lab tests may include CBC with differential (look for eosinophilia associated with parasites), LFTs (alkaline phosphatase is the best screening test for hepatobiliary disorders), renal function tests, thyroid function tests
• Rule out internal malignancies (e.g., chest X-ray, mammogram, stool for occult blood)
• Other labs to consider: HIV test, hepatitis B and C panel, serum iron and ferritin, serum and urine protein electrophoresis, stool for ova and parasites, blind skin biopsy with or without immunofluorescence

Treatment

• Symptomatic treatment may be sufficient
  –Take short cool or lukewarm baths and showers; wash with a mild soap and apply soap only to malodorous areas
  –Apply an emollient immediately after bathing
  –Emollients with menthol provide a cooling sensation
  –Emollients with phenol or camphor provide an anesthetic effect
  –Low-dose topical corticosteroids may be used, but only over a short duration
  –Oral antihistamines, such as hydroxyzine or diphenhydramine, may be used but are sedating
  –Nonsedating antihistamines are not as effective in reducing pruritus
  –Ultraviolet light therapy may be helpful in some cases

• Ultimate treatment is aimed at the underlying etiology

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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