Pruritus
Pruritus: Excerpt from Handbook of Signs & Symptoms (Third Edition)
Commonly provoking scratching to gain relief, this unpleasant itching sensation affects the skin, certain mucous membranes, and the eyes. Most severe at night, pruritus may be exacerbated by increased skin temperature, poor skin turgor, local vasodilation, dermatoses, and stress.
The most common symptom of dermatologic disorders, pruritus may also result from a local or systemic disorder or from drug use. Physiologic pruritus, such as pruritic urticarial papules and plaques of pregnancy, may occur in primigravidas late in the third trimester. Pruritus can also stem from emotional upset or contact with skin irritants.
History and physical examination
If the patient reports pruritus, have him describe its onset, frequency, and intensity. If pruritus occurs at night, ask whether it prevents him from falling asleep or awakens him after he falls asleep. (Generally, pruritus related to dermatoses prevents — but doesn’t disturb — sleep.) Is the itching localized or generalized? When is it most severe? How long does it last? Is there a relationship to activities (physical exertion, bathing, applying makeup, or the use of perfumes)?
Ask the patient how he cleans his skin. In particular, look for excessive bathing, harsh soaps, contact allergy, and excessively hot water. Does he have occupational exposure to known skin irritants, such as glass fiber insulation or chemicals? Ask about the patient’s general health and the medications he takes (new medications are suspect). Has he recently traveled abroad? Does he have pets? Does anyone else in the house report itching? Does exercise, stress, fear, depression, or illness seem to aggravate the itching? Ask about contact with skin irritants, previous skin disorders, and related symptoms. Then obtain a complete drug history.
Examine the patient for signs of scratching, such as excoriation, purpura, scabs, scars, or lichenification. Look for primary lesions to help confirm dermatoses.
Medical causes
Anemia (iron deficiency)
Iron deficiency anemia occasionally produces pruritus. Initially asymptomatic, anemia can later cause exertional dyspnea, fatigue, listlessness, pallor, irritability, a headache, tachycardia, poor muscle tone and, possibly, murmurs. Chronic anemia causes spoon-shaped (koilonychia) and brittle nails (cheilosis), cracked mouth corners, a smooth tongue (glossitis), and dysphagia.
Anthrax (cutaneous)
Anthrax is an acute infectious disease caused by the gram-positive, spore-forming bacterium Bacillus anthracis. It can occur in humans who are exposed to infected animals, tissue from infected animals, or biological warfare. Cutaneous anthrax occurs when the bacterium enters a cut or an abrasion on the skin. The infection begins as a small, painless or pruritic macular or papular lesion resembling an insect bite. Within 1 to 2 days, it develops into a vesicle and then a painless ulcer with a characteristic black, necrotic center. Lymphadenopathy, malaise, a headache, or a fever may develop.
Conjunctivitis
All forms of conjunctivitis cause eye itching, burning, and pain along with photophobia, conjunctival injection, a foreign-body sensation, excessive tearing, and a feeling of fullness around the eye. Allergic conjunctivitis may also cause milky redness and a stringy eye discharge. Bacterial conjunctivitis typically causes brilliant redness and a mucopurulent discharge that may make the eyelids stick together. Fungal conjunctivitis produces a thick, purulent discharge and crusting and sticking of the eyelid. Viral conjunctivitis may cause copious tearing — but little discharge — and preauricular lymph node enlargement.
Dermatitis
Several types of dermatitis can cause pruritus accompanied by a skin lesion. Atopic dermatitis begins with intense, severe pruritus and an erythematous rash on dry skin at flexion points (antecubital fossa, popliteal area, and neck). During a flare-up, scratching may produce edema, scaling, and pustules. With chronic atopic dermatitis, lesions may progress to dry, scaly skin with white dermatographia, blanching, and lichenification.
Mild irritants and allergies can cause contact dermatitis, with itchy small vesicles that may ooze and scale and are surrounded by redness. A severe reaction can produce marked localized edema.
Dermatitis herpetiformis, most common in men between ages 20 and 50, initially causes intense pruritus and stinging. Between 8 and 12 hours later, symmetrically distributed lesions form on the buttocks, shoulders, elbows, and knees. Sometimes, they also form on the neck, face, and scalp. These lesions are erythematous and papular, bullous, or pustular.
Hepatobiliary disease
An important diagnostic clue to liver and gallbladder disease, pruritus is commonly accompanied by jaundice and may be generalized or localized to the palms and soles. Other characteristics include right upper quadrant pain, clay-colored stools, chills and a fever, flatus, belching and a bloated feeling, epigastric burning, and bitter fluid regurgitation. Later, liver disease may produce mental changes, ascites, bleeding tendencies, spider angiomas, palmar erythema, dry skin, fetor hepaticus, enlarged superficial abdominal veins, bilateral gynecomastia, testicular atrophy or menstrual irregularities, and hepatomegaly.
Herpes zoster
Within 2 to 4 days of a fever and malaise, pruritus, paresthesia or hyperesthesia, and severe, deep pain from cutaneous nerve involvement develop on the trunk or the arms and legs in a dermatome distribution. Up to 2 weeks after initial symptoms, red, nodular skin eruptions appear on the painful areas and become vesicular. About 10 days later, the vesicles rupture and form scabs.
Leukemia (chronic lymphocytic)
Pruritus is an uncommon finding in leukemia. More characteristic signs and symptoms include fatigue, malaise, generalized lymphadenopathy, a fever, hepatomegaly, splenomegaly, weight loss, pallor, bleeding, and palpitations.
Lichen simplex chronicus
Persistent rubbing and scratching cause localized pruritus and a circumscribed scaling patch with sharp margins. Later, the skin thickens and papules form.
Myringitis (chronic)
Myringitis produces pruritus in the affected ear, along with a purulent discharge and gradual hearing loss.
Pediculosis
A prominent symptom, pruritus occurs in the area of infestation. Pediculosis capitis (head lice) may also cause scalp excoriation from scratching, along with matted, foul-smelling, lusterless hair; occipital and cervical lymphadenopathy; and oval, gray-white nits on hair shafts.
Pediculosis corporis (body lice) initially causes small red papules (usually on the shoulders, trunk, or buttocks), which become urticarial from scratching. Later, rashes or wheals may develop. Untreated, pediculosis corporis produces dry, discolored, thickly encrusted, scaly skin with bacterial infection and scarring. In severe cases, it produces a headache, a fever, and malaise.
With pediculosis pubis (pubic lice), scratching commonly produces skin irritation. Nits or adult lice and erythematous, itching papules may appear in pubic hair or in hair around the anus, abdomen, or thighs.
Pityriasis rosea
Pityriasis rosea occasionally produces mild pruritus that’s aggravated by a hot bath or shower. It usually begins with an erythematous herald patch — a slightly raised, oval lesion about 2 to 6 cm in diameter. After a few days or weeks, scaly yellow-tan or erythematous patches erupt on the trunk and extremities and persist for 2 to 6 weeks. Occasionally, these patches are macular, vesicular, or urticarial.
Psoriasis
Pruritus and pain are common in psoriasis. This skin disorder typically begins with small erythematous papules that enlarge or coalesce to form red elevated plaques with silver scales on the scalp, chest, elbows, knees, back, buttocks, and genitals. Nail pitting may occur.
Scabies
Typically, scabies causes localized pruritus that awakens the patient. It may become generalized and persist for up to 2 weeks after treatment. Threadlike lesions several millimeters long appear with a swollen nodule or red papule.
Gender Cue: In males, crusty lesions may form on the glans penis, penile shaft, and scrotum. In females, lesions may also be found on or around the nipples. In both sexes, the lesions have a predilection for skin folds. Crusty excoriated lesions form on the wrists, elbows, axillae, waistline, behind the knees, and ankles. Excoriation from scratching is common.
Tinea pedis
Tinea pedis is a fungal infection that causes severe foot pruritus, pain with walking, scales and blisters between the toes, and a dry, scaly squamous inflammation on the entire sole.
Urticaria
Extreme pruritus and stinging occur as transient, erythematous or whitish wheals form on the skin or mucous membranes. Prickly sensations typically precede the wheals, which may affect any part of the body and may range from pinpoint to palm-sized or larger.
Vaginitis
Vaginitis commonly causes localized pruritus and a foul-smelling vaginal discharge that may be purulent, white or gray, and curdlike. Perineal pain and urinary dysfunction may also occur.
Other causes
Herb Alert
Ingestion of fruit pulp from the ginkgo tree can cause rapid formation of vesicles, resulting in severe itching.
Bedbug bites
Typically, bedbug bites produce itching and burning over the ankles and lower legs, along with clusters of purpuric spots.
Drug hypersensitivity
When mild and localized, an allergic reaction to such drugs as penicillin and sulfonamides can cause pruritus, erythema, an urticarial rash, and edema. However, with a severe drug reaction, anaphylaxis may occur.
Special considerations
Administer a topical or oral corticosteroid, an antihistamine, or a tranquilizer, as ordered. If the patient doesn’t have a localized infection or skin lesions, suspect a systemic disease and prepare him for a complete blood count and differential, erythrocyte sedimentation rate, protein electrophoresis, and radiologic studies.
Pediatric pointers
Many adult disorders also cause pruritus in children, but they may affect different parts of the body. For instance, scabies may affect the head in infants, but not in adults. Pityriasis rosea may affect the face, hands, and feet of adolescents.
Some childhood diseases, such as measles and chickenpox, can cause pruritus.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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