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Background
This is the medical term for itching. It may be associated with underlying systemic illnesses or may be a bothersome itch. A persistent pruritus should always be investigated by a physician. This differs from urticaria which is associated with wheals, flares, and reddening. Nontheless, both conditions present with itching or pruritus.
OUTLINE
DISEASE ASSOCIATIONS CHARACTERIZATION GENERAL Pruritus: pathogenesis, therapy, and significance in systemic disease states.
Gilchrest BA.
Arch Intern Med 1982 Jan;142(1):101-5 Abstract quote
Pruritus is a cutaneous sensation sharing neural receptors and pathways with pain but is characterized by its own precipitants, potentiators, and range of severity. Among patients with generalized pruritus, the prevalence of systemic disease has been reported as 10% to 50%, with renal, hepatic, hematopoietic, or endocrine causes most commonly identified. Malignant neoplasms, neurologic disorders, certain drugs, or advanced age also may be responsible. Although the pathogenesis of pruritus is unknown, clinically AG event potential mediators have been investigated in several settings.
Therapy often fails when the underlying disorder cannot be corrected, but por pruritus associated with chronic renal failure or hepatic cholestasis, specific and usually effective treatments exist.
BURNS Severe itching in the patient with burns.
Vitale M, Fields-Blache C, Luterman A.
University of South Alabama Burn Center, Mobile
J Burn Care Rehabil 1991 Jul-Aug;12(4):330-3 Abstract quote
After discharge, the patient with burns is often plagued with persistent, unrelenting itching. The purpose of this study was to document the incidence and severity of itching in discharged patients with burns, to determine factors that may help in prediction of the problem, and to study the effectiveness of Benadryl (Parke-Davis, Morris Plains N.J.), Atarax (Roerig Div. of Pfizer Inc., New York, N.Y.) and Polyhist Forte (Mikart Inc., Atlanta, Ga.) in relieving the symptom.
All adult patients who were discharged to our outpatient clinic were entered into this prospective study. Patients were started on one of the three agents, and agents were changed monthly in a randomized fashion. Severity of itching was determined by a visual linear analogue scale. The study population had a mean age of 35.9 +/- 12.8 years, and a mean burn size of 19.1% +/- 15.3% total body surface area. Eighty-seven percent of discharged patients complained of itching. The average severity of the problem was 7.6 +/- 1.9. A significant difference (p less than 0.05) among groups was found when the population was analyzed for size of burn and duration of time to wound closure. Symptoms varied with anatomic area burned. One hundred percent of patients with leg burns and 70% of those with arm burns complained of itching. Facial burns did not cause itching in any of the patients.
The agents that were tested produced complete relief in only 20% of patients, partial relief in 60%, and no relief in 20%. There were no differences in response to the three agents tested. All three of the drugs that were tested had similar onset of action.(
END STAGE RENAL DISEASE
Prevalence and characterization of uremic pruritus in patients undergoing hemodialysis: Uremic pruritus is still a major problem for patients with end-stage renal disease.
Zucker I, Yosipovitch G, David M, Gafter U, Boner G.
J Am Acad Dermatol. 2003 Nov;49(5):842-6. Abstract quote
BACKGROUND: Pruritus is a common disabling problem in patients with advanced end-stage renal disease. Few studies have evaluated the clinical characteristics of uremic itch.
OBJECTIVES: The aim of this multicenter study was to provide a comprehensive description of the prevalence and clinical characteristics of pruritus affecting patients with end-stage renal disease who are undergoing hemodialysis.
METHODS: A detailed questionnaire recently developed was used to evaluate pruritus in 219 patients undergoing hemodialysis treatment in 3 dialysis units. We examined the relationship of the quality of dialysis and various factors and medical parameters to itch.
RESULTS: Pruritus was a common symptom in the study population. Approximately 66% of the patients had pruritus at some point, and 48% were affected by it at the time of the study. There was no correlation between the occurrence of pruritus and demographic or medical parameters (type of kidney disease, medical management, dialysis efficacy as expressed by Kt/V) of the patient. The data suggest that uremic pruritus tends to be prolonged, frequent, and intense, and it can impair the patient's quality of life including a negative effect on sleep and mood. Major factors found to exacerbate pruritus include rest, heat, dry skin, and sweat. Major factors found to reduce pruritus include activity, sleep, hot and cold shower, and cold. Treatment with angiotensin inhibitors seemed to be more common among those with uremia who had itch (P =.02) whereas furosemide was more commonly used among those who never itched (P =.002).
CONCLUSION: This study provides a detailed description of uremic pruritus with new data on its characteristics including affective and sensory dimensions and associated symptoms.HELICOBACTER INFECTION
The effect of antibiotic therapy for patients infected with Helicobacter pylori who have chronic urticaria.
Federman DG, Kirsner RS, Moriarty JP, Concato J.
J Am Acad Dermatol. 2003 Nov;49(5):861-4. Abstract quote
BACKGROUND: Several small trails looking at antibiotic therapy targeted at Helicobacter pylori for the treatment of chronic urticaria have peen published and have had conflicting results. We conducted a systematic review of existing studies to help answer the clinical question of whether this therapy has a role in the treatment of chronic urticaria.
METHODS: We identified studies published in the English language with searches of MEDLINE, PREMEDLINE, American College of Physicians Journal Club, Database of Abstracts of Reviews of Effectiveness, and Cochrane Libraries using the key words "Helicobacter pylori" and "urticaria." Relevant studies from bibliography reviews were also included. Studies included met the following criteria: (1) patients had urticaria for at least 6 weeks; (2) other known causes of urticaria were excluded by appropriate testing; (3) the initial diagnosis of H pylori infection was made by either serology, urea breath test, or upper endoscopy; and (4) an adequate trial of an antibiotic with known activity against H pylori was completed.
RESULTS: In all, 10 studies met our inclusion criteria. The rate of remission of urticaria when H pylori was eradicated was 30.9% (59/191) compared with 21.7% (18/83) when H pylori was not eradicated; the background remission rate among control subjects without H pylori infection was 13.5% (10/74). When data from the 10 studies were combined, eradication of H pylori was both quantitatively and statistically associated with remission of urticaria (odds ratio 2.9; 95% confidence interval 1.4-6.8; P =.005).
CONCLUSION: We found that resolution of urticaria was more likely when antibiotic therapy was successful in eradication of H pylori infection than when patients who were infected did not achieve eradication. These results suggest that clinicians, after considering other causes of urticaria, should constitute (1) testing for H pylori; (2) treating with appropriate antibiotics if H pylori is present; and (3) confirming successful eradication of infection.HEPATITIS AND HIV Pruritus in patients with chronic human immunodeficiency virus, hepatitis B and C virus infections.
Bonacini M.
Keck School of Medicine of the University of Southern California, Los Angeles 90033, USA.
Dig Liver Dis 2000 Oct;32(7):621-5 Abstract quote
AIM: The prevalence of pruritus was prospectively determined in 310 patients of whom 119 had hepatitis C virus infection, 91 hepatitis C virus and human immunodeficiency virus, 51 human immunodeficiency virus infection alone, 31 hepatitis B virus and human immunodeficiency virus coinfection and 18 were HBsAg carriers.
RESULTS: Patients in the first three groups were more likely to complain of itching (22%, 28% and 25%, respectively) than HBsAg carriers (8.2%, p=0.01. Laboratory data were not different between groups, except for the human immunodeficiency virus group, whose alkaline phosphatase levels were highest, and CD4 counts were lowest (median 30 cells/mm3). Patients with hepatitis C, including those with human immunodeficiency virus, had similar hepatitis C virus RNA levels in patients with or without pruritus. There was no difference in hepatic inflammation or fibrosis between those with and those without pruritus.
CONCLUSION: 20% of patients with chronic hepatitis C and 8% of hepatitis B patients complain of pruritus. Patients with pruritus have laboratory and histologic parameters comparable to those without.
IDIOPATHIC Pruritus of unknown origin: A retrospective study
Matthew J. Zirwas, MD
Mark P. Seraly, MDPittsburgh, Pennsylvania
J Am Acad Dermatol 2001;45:892-6. Abstract quote
Background: Pruritus of unknown origin is a common complaint, and systemic causes must be considered. However, there is little data on how frequently systemic causes are responsible or whether any patient characteristics make a systemic cause more likely.
Objective: We attempted to determine how frequently pruritus of unknown origin had a systemic etiology in an outpatient population seen in a university dermatology department and whether any patient characteristics made a systemic explanation more likely.
Methods: This is a retrospective study using chart reviews and telephone interviews to collect data.
Results: Of 50 patients, 11 had a systemic cause of pruritus. Pruritus was the initial symptom of systemic disease in 7 of these patients. No patient characteristics were statistically associated with systemic causes of pruritus.
Conclusion: Pruritus of unknown origin was the initial symptom of a systemic disease in 7 of 50 patients presenting to a dermatology clinic with this complaint. The underlying diseases included hypothyroidism, gastric adenocarcinoma, hepatitis C, HIV, laryngeal carcinoma, graft-versus-host disease, and chronic lymphocytic leukemia.
PATHOGENESIS CHARACTERIZATION Role of antigen-induced cytokine release in atopic pruritus.
Lippert U, Hoer A, Moller A, Ramboer I, Cremer B, Henz BM.
Department of Dermatology, Virchow-Klinikum, Humboldt Universitat zu Berlin, Germany
Int Arch Allergy Immunol 1998 May;116(1):36-9 Abstract quote
In order to further evaluate the role of cytokines in the induction of atopic pruritus, leukocytes from 10 atopic eczema patients or 10 nonallergic controls were stimulated in vitro with mite or birch pollen antigen for 1 and 4 days.
Subjects were prick-tested with the supernatants, and whealing and itching were evaluated 20 and 60 min later. The supernatants were also examined for the contents of GM-CSF, IL-2, IL-6 and IL-8 by ELISA and TNFalpha. Two hours prior to testing, the antihistamine cetirizine (20 mg) or a placebo tablet were given to the patients according to a randomized, double-blind study protocol. After pricking with antigen-stimulated leukocyte supernatants, 6 of 10 patients but no controls reacted mostly at 20 min with whealing and/or pruritus. In the cetirizine-treated group, no decrease in these skin reactions was seen compared to placebo. Analysis for cytokines showed increased levels of IL-8 in allergen-stimulated samples, with no correlation to the induction of itching or whealing by these supernatants. IL-6 levels were low and variable, and GM-CSF, IL-2 and TNFalpha levels were always below standard values.
These data show that leukocytes selectively release IL-8 in response to in vitro antigen stimulation. They furthermore provide additional support for the concept that as yet to be identified products play a role in atopic pruritus.
PROGNOSIS AND TREATMENT CHARACTERIZATION PROGNOSTIC FACTORS TREATMENT Differential effects of new-generation H1-receptor antagonists in pruritic dermatoses.
Henz BM, Metzenauer P, O'Keefe E, Zuberbier T.
Department of Dermatology, Virchow Klinikum, Humboldt University, Berlin, Germany.
Allergy 1998 Feb;53(2):180-3 Abstract quote
In search of an improved treatment of pruritic dermatoses, we have studied azelastine, a novel H1-receptor antagonist, during a 2-week treatment period, using a double-blind, placebo-controlled design. The potent H1-antagonist cetirizine was used for comparison.
Symptoms were recorded daily by the patients on a diary card, using a 4-point scale. The same parameters and adverse events were evaluated at weekly intervals, and global improvement was evaluated at the end of treatment. In all 230 evaluable patients with moderate to severe itching, azelastine caused an overall significant improvement in comparison to placebo (P = 0.02), with significance also for pruritus (P = 0.01 after 1 week and P = 0.02 after 2 weeks). Both drugs reduced itching more effectively in urticaria than in atopic eczema. Azelastine was superior to cetirizine in reducing pruritus, whereas cetirizine caused a more marked reduction of whealing. Both drugs rarely caused fatigue and dry mouth, but taste perversion occurred only in azelastine-treated patients (9.7%) and headaches only with cetirizine (10.4%).
Therefore, the two H1-blockers exert differential effects on pruritus verses whealing and a distinctive adverse events pattern. The data also underline the low efficacy of antihistamines in atopic eczema, compared to urticaria.
Cutaneous field stimulation in the treatment of severe itch.
Wallengren J, Sundler F.
Department of Dermatology, Lund University Hospital, SE-221 85 Lund, Sweden.
Arch Dermatol 2001 Oct;137(10):1323-5 Abstract quote
OBJECTIVE: To evaluate the efficacy of cutaneous field stimulation of C fibers for the treatment of itchy skin and its effect on peripheral nerve fibers as shown in skin biopsy specimens.
DESIGN: We conducted an open-label uncontrolled study of 19 patients with itching. Each patient applied a flexible plate containing electrodes to the itchy area for 20 minutes at a time once daily for 5 weeks to stimulate nerve fibers with a constant current (0.8 mA). Skin biopsy specimens were collected before treatment and at the end of treatment and were immunostained for calcitonin gene-related peptide and protein gene product 9.5.
SETTING: University hospital in Lund, Sweden.
PATIENTS: Sixteen patients with nostalgia paresthetica or brachioradial pruritus and 3 with generalized itch.
INTERVENTIONS: Cutaneous field stimulation and punch biopsies of the itchy skin.
MAIN OUTCOME MEASURES: Visual analog scale for assessment of itching and counting the immunoreactive nerve fibers in 3-mm biopsy specimens.
RESULTS: Patients with localized itching experienced a reduction in mean values on the visual analog scale (from 78% before treatment to 42% by the end of the fifth week). The number of protein gene product 9.5- immunoreactive nerve fibers in the epidermis was reduced by 40% by the end of treatment compared with baseline values.
CONCLUSIONS: Cutaneous field stimulation is an effective alternative for the treatment of localized itching. The reduction in itching is accompanied by degeneration of the epidermal nerve fibers, as evidenced by the loss of protein gene product 9.5 immunoreactivity.
Comparison of the effects of levocetirizine and loratadine on histamine-induced wheal, flare, and itch in human skin.
Clough GF, Boutsiouki P, Church MK.
Dermatopharmacology Unit, Allergy and Inflammation Sciences, School of Medicine, University of Southampton, Southampton, UK.
Allergy 2001 Oct;56(10):985-8 Abstract quote
BACKGROUND: This randomized, double-blind, crossover study compared the effects of the R-enantiomer of cetirizine, levocetirizine, with those of loratadine on the wheal, flare, and itch response to histamine in human skin.
METHODS: Levocetirizine (5 mg), loratadine (10 mg), or placebo was taken orally 4 h before the intradermal injection of histamine (20 microl, 100 microM) or the control vehicle into the forearm skin of healthy volunteers. Flare areas were assessed by scanning laser Doppler imaging before and at 30-s intervals for a period of 9 min. Wheal areas were measured by planimetry at 10 min. Itch was scored every 30 s with a visual analogue scale.
RESULTS: After placebo administration, the mean peak flare area was 23.01+/-1.94 cm(2), the wheal area 248+/-27 mm(2), and the cumulative itch score 28.8+/-4.6% (mean+/-SEM). Levocetirizine reduced the flare, wheal, and itch by 60%, 68%, and 91%, respectively (all P<0.001, Student's t-test for paired data). The effects of loratadine were variable and not statistically significant.
CONCLUSION: Levocetirizine (5 mg) is a potent inhibitor of the effects of histamine in human skin with an efficacy that exceeded that of loratadine (10 mg) when single doses of the drugs were administered 4 h before the test.
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