Pruritus
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
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 hefalls 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 (exercising, bathing, applying makeup, or using 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 any 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.
Physical assessment
Observe 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)
Anemia occasionally produces pruritus. Initially asymptomatic, anemia can later cause exertional dyspnea, fatigue, listlessness, pallor, irritability, 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)
A cutaneous anthrax 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, headache, or 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 dermatographism, 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.
Enterobiasis
Also known as pinworm or seatworm, this helminthic infection produces intense perianal pruritus, especially at night, when the female worm leaves the anus to deposit ova. Pruritus causes irritability, scratching, skin irritation and, sometimes, vaginitis.
Hemorrhoids
Anal pruritus may occur in patients with hemorrhoids along with rectal pain and constipation. External hemorrhoids may be seen outside the external anal sphincter; internal hemorrhoids are less obvious and less painful but more likely to cause rectal bleeding.
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 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
In herpes zoster, within 4 days of 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.
Hodgkin’s disease
Hodgkin’s disease occasionally causes severe and unexplained itching. As the disease progresses, pruritus may become severe and unresponsive to treatment. Early nonspecific findings include persistent fever (occasionally, cyclic fever and chills), night sweats, fatigue, weight loss, malaise, and painless swelling of a cervical lymph node. Other lymph nodes may enlarge rapidly and cause pain, or they may enlarge slowly and be painless. Later findings include retroperitoneal node enlargement, hepatomegaly, splenomegaly, dyspnea, dysphagia, dry cough, hyperpigmentation, jaundice, and pallor.
Lichen simplex chronicus
Lichen simplex chronicus is due to persistent rubbing and scratching of the skin, causing localized pruritus and a circumscribed scaling patch with sharp margins. Later, the skin thickens and papules form. This condition usually affects areas easily reached, such as ankles, lower legs, anogenital area, back of neck, and ears.
Pediculosis
A prominent symptom of pediculosis, 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. Left untreated, pediculosis corporis produces dry, discolored, thickly encrusted, scaly skin with bacterial infection and scarring. In severe cases, it produces headache, 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 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-tanor erythematous patches erupt on the trunk and extremities and persist for 2 to 6 weeks. Occasionally, these patches are macular, vesicular, or urticarial.
Polycythemia vera
Polycythemia vera, a hematologic disorder, can produce pruritus that’s generalized or localized to the head, neck, face, and extremities. The itching is typically aggravated by a hot bath or shower and can last from a few minutes to an hour. The patient’s oral mucosa may be deep purplish red, especially on the gingivae and tongue. His engorged gingivae ooze blood with even slight trauma.
Related findings include headache, dizziness, fatigue, dyspnea, paresthesia, impaired mentation, tinnitus, double or blurred vision, scotoma, hypotension, intermittent claudication, urticaria, ruddy cyanosis, and ecchymosis. GI effects include gastric distress, weight loss, and hepatosplenomegaly.
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.
Renal failure (chronic)
Pruritus may develop gradually or suddenly with chronic renal failure. It may be accompanied by ammonia breath odor, oliguria or anuria, lassitude, fatigue, irritability, decreased mental acuity, convulsions, coarse muscular twitching, muscle cramps, peripheral neuropathies,and coma. Renal failure also causes diverse GI signs and symptoms, such as anorexia, constipation or diarrhea, nausea, and vomiting.
Scabies
Typically, scabies causes localized pruritus that awakens the patient. It may become generalized and persist up to 2 weeks after treatment. Threadlike lesions several millimeters long appear with a swollen nodule or red papule.
Thyrotoxicosis
Generalized pruritus may precede or accompany the characteristic signs and symptoms of thyrotoxicosis: tachycardia, palpitations, weight loss despite increased appetite, diarrhea, tremors, an enlarged thyroid, dyspnea, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos.
Tinea pedis
Tinea pedis, also called athlete’s foot, 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. The affected skin may appear red and inflamed.
Urticaria
With 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 foul-smelling vaginal discharge that may be purulent, white or gray, and curdlike. Perineal pain and urinary symptoms, such as burning and frequency, may also occur.
Other causes
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.
Patient counseling
Suggest ways to control pruritus. For example, tell your patient to avoid scratching or rubbing the itchy areas. Advise him to keep fingernails short to avoid skin damage from any unconscious scratching. Recommend taking tepid baths, using little soap and rinsing thoroughly. Tell him to apply an emollient lotion after bathing to soften and cool the skin. Show the patient how to use topical ointments after bathing to soften and cool the skin.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Itchy rash
Read excerpts from these other book chapters related to Itchy rash:
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- "A Pocket Manual of Differential Diagnosis" (1999)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "Nursing: Interpreting Signs and Symptoms" (2007)
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- "Differential Diagnosis in Primary Care" (2007)
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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Itchy rash
» Next page: Pustular rash (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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