Pruritus (Itching) - Causes, Symptoms and Treatment
Pruritus, commonly known as itching, is an unpleasant skin sensation that triggers a strong urge to scratch. It can have many causes and may occur locally or all over the body.
Things worth knowing about "Pruritus (Itching)"
Pruritus, commonly known as itching, is an unpleasant skin sensation that triggers a strong urge to scratch. It can have many causes and may occur locally or all over the body.
What is Pruritus (Itching)?
Pruritus, commonly referred to as itching, is an uncomfortable sensation of the skin or mucous membranes that triggers an involuntary urge to scratch. It is one of the most frequently encountered dermatological symptoms and can occur acutely or chronically. Chronic pruritus is defined as itching that persists for more than six weeks.
Causes
Pruritus can be triggered by a wide variety of conditions and external factors. It is generally classified into the following categories:
Dermatological Causes
- Atopic dermatitis (eczema): A common chronic skin condition associated with intense itching
- Psoriasis: An inflammatory skin disease causing scaly, itchy plaques
- Contact dermatitis: Allergic or irritant skin reactions
- Urticaria (hives): Triggered by allergens or physical stimuli
- Fungal skin infections (e.g., athlete's foot, candidiasis)
- Parasitic infestations (e.g., scabies, pubic lice)
- Dry skin (xerosis cutis), particularly in older adults
Systemic Causes
- Liver diseases (e.g., cholestatic pruritus in bile duct disorders)
- Kidney diseases (uraemic pruritus in chronic kidney failure)
- Haematological conditions (e.g., polycythaemia vera, lymphomas)
- Thyroid disorders (hyperthyroidism or hypothyroidism)
- Diabetes mellitus
- Iron deficiency
- HIV infection and other infectious diseases
Neurological and Psychogenic Causes
- Neuropathic pruritus (e.g., in herpes zoster, polyneuropathy)
- Psychogenic or somatoform pruritus associated with depression or anxiety disorders
Medication-Induced Causes
- Opioid-induced pruritus
- Reactions to ACE inhibitors, diuretics, antibiotics, or other medications
Symptoms
The primary symptom is the itching sensation itself, which can vary in intensity and location. Associated symptoms may include:
- Skin redness and signs of inflammation due to scratching
- Skin excoriations, lesions, or secondary wound infections
- Lichenification: Thickened, leathery skin as a result of chronic scratching
- Sleep disturbances and psychological distress in chronic cases
- Scratch marks and crusts on the skin
Diagnosis
Diagnosis requires a thorough medical history and physical examination. Depending on the suspected cause, the following diagnostic measures may be used:
- Blood tests: Full blood count, liver and kidney function, thyroid levels, blood glucose, iron status
- Skin biopsy: Tissue examination for unclear skin changes
- Allergy testing: Prick test or patch test when an allergic cause is suspected
- Imaging studies: Ultrasound or CT scan if an internal disease is suspected
- Dermoscopy for parasitic infestations or pigmented lesions
Treatment
Treatment depends on the underlying cause. In addition, symptomatic treatment options are available:
Treatment of the Underlying Cause
When an underlying condition is identified, treating it takes priority - for example, managing liver disease, optimising renal replacement therapy, or discontinuing the triggering medication.
Topical Therapy
- Emollients and moisturising lotions: First-line therapy for dry skin
- Topical corticosteroids: Short-term use for inflammatory skin conditions
- Topical calcineurin inhibitors (e.g., tacrolimus, pimecrolimus): For atopic dermatitis
- Menthol-based cooling gels: Relief of acute itching
- Capsaicin cream: For neuropathic pruritus
Systemic Therapy
- Antihistamines (e.g., cetirizine, loratadine): Particularly effective for allergic pruritus and urticaria
- Immunosuppressants (e.g., ciclosporin, dupilumab): For severe atopic dermatitis
- Antidepressants (e.g., mirtazapine, doxepin): For chronic and psychogenic pruritus
- Opioid antagonists (e.g., naltrexone): For cholestatic or uraemic pruritus
- Gabapentin / pregabalin: For neuropathic pruritus
General Measures
- Avoidance of trigger factors (e.g., certain soaps, synthetic fabrics, excessive sweating)
- Short, lukewarm showers instead of hot baths
- Wearing light, breathable clothing
- Psychotherapy for chronic pruritus with psychogenic components
When to See a Doctor?
Medical consultation is recommended if the itching:
- persists for more than two weeks
- affects the entire body (generalised pruritus)
- occurs without visible skin changes
- is accompanied by general symptoms such as fever, weight loss, or night sweats
- significantly impairs sleep or quality of life
References
- Weisshaar E. et al. - Guideline on chronic pruritus. AWMF Guideline No. 013-048 (2022). German Dermatological Society.
- Ständer S. - Chronic Pruritus. New England Journal of Medicine, 386:760-771 (2022). DOI: 10.1056/NEJMra2109873.
- Twycross R. et al. - Itch: Scratching More Than the Surface. Quarterly Journal of Medicine, 96(1):7-26 (2003). Oxford University Press.
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