HNY Central Digital Repository - York

Pruritus is defined as the desire to scratch. When generalised it affects most or all of the body.

Can lead to anxiety, depression, skin damage etc

Check for lymph nodes (cervical, axillae and groins) and organomegaly i.e. hepatomegaly, splenomegaly.

A full general examination is essential, repeated if symptoms don’t settle

Causes

Primary Skin Conditions

• Dry skin, eczema, scabies are the most common - examine the skin very carefully. Urticaria can come and go so ask about wheals that last less than 24 hours. Look for urticaria at pressure sites or on gentle friction suggesting dermographism.

Non-Dermatological Itch

• If there is no rash except excoriations consider:
  • Anaemia, especially iron deficiency
  • Uraemia
  • Cholestasis, autoimmune liver disease
  • Hypo and hyper-thyroidism
  • Lymphoma-itch may precede diagnosis by several years.
  • Carcinoma-especially in middle aged/elderly
  • Psychological
  • Drugs that might cause itching, for example opioids, statins, angiotensin-converting enzyme [ACE] inhibitors

Management

• Advise smoking cessation
• Encourage weight loss if appropriate
• Strong advice not to scratch is very important due to the itch/scratch/itch cycle-“the more you scratch, the more you itch”. Also advise to keep cool, keep nails short and smooth. Cotton gloves at night can help to avoid skin damage. Luke warm baths or showers or cool
• flannels can help. Applying emollients can help to reduce itch due to their cooling effect. Distraction can help many too.
• Standard emollients and soap substitutes are essential – see Emollients Guidance/Medal Ranking for full information on prescribing
• If an emollient alone does not provide adequate relief, consider a trial (100g) of an emollient with an active ingredient for example menthol 0.5% or 1% in aqueous cream or topical crotamiton (Eurax®).
• The use of topical steroids should be discouraged unless there is a primary skin cause such as eczema
• Sedating antihistamines:
  • Chlorphenamine 8mg nocte or 4mg tds
    Hydroxyzine 25mg nocte (please be aware of MHRA Drug Safety Update on hydroxyzine – maximum daily dose is 100mg for adults and 50mg in the elderly.
    Prescribe the lowest effective dose for as short a time as possible.
    Care with sedative antihistamines –warn re drowsiness especially in elderly.
• Alternative treatments - beneficial for any associated anxiety: amitriptyline, sertraline
  If features suggestive of dermographism consider non-sedating antihistamine e.g. fexofenadine 180mg od or loratadine 10mg od
   

See BNF for additional prescribing information

None

Referral Criteria

• Unresponsive to above treatments and no underlying cause found.

Information to include in referral letter

• Investigations as below, treatments already tried
• Relevant past medical/surgical history
• Current regular medication
• BMI/Smoking status

Investigations prior to referral

• FBC, U/E, LFT, TFT, ferritin, CRP HbA1c
• CXR, urinalysis if above negative
• Consider checking B12/folate depending on FBC result.

Patient information leaflets/ PDAs

http://www.dermnetnz.org/systemic/itch.html for clinicians

http://www.patient.co.uk/doctor/Itching.htm for clinicians

http://www.patient.co.uk/health/itching-leaflet for PIL

Reference

NICE CKS – Itch (March 2016)

Responsible GP: Dr Alison Hunter

Responsible Consultant: Kathryn Thomson