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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.

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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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