Don

You've Got an Itch...

ALERT: The Use of Cortisone Creams Topically Can Lead to Adrenal Insufficiency

Pruritus is the medical term for Itching, or simply put, a sensation that a person instinctively attempts to relieve by scratching or rubbing.

According to medical definitions Pruritus is a symptom and not a disease. It may accompany a primary skin disease or a systemic disease. Skin diseases causing severe pruritus and lesions include scabies, pediculosis, insect bites, urticaria, atopic dermatitis, contact dermatitis, lichen planus, miliaria, and dermatitis herpetiformis. Dry skin, especially in the elderly, often causes severe generalized pruritus.

Systemic conditions that cause generalized pruritus, usually without skin lesions, include obstructive biliary disease, uremia (frequently associated with hyperparathyroidism), lymphomas, leukemias, and polycythemia rubra vera. Pruritus may also occur during the later months of pregnancy. Many drugs (especially barbiturates and salicylates) can cause pruritus. Less well-defined associations with generalized pruritus include hyperthyroidism, diabetes mellitus, and internal cancers of many types. Pruritus is uncommonly purely psychogenic.

Symptoms and Signs - Persistent scratching may produce redness, linear urticarial papules, excoriation of preexisting papules, fissures, and elongated crusts along scratch lines, which may obscure the underlying disease. Lichenification and pigmentation may also result from prolonged scratching and rubbing. Occasionally, patients who complain of severe generalized pruritus have few signs of scratching or rubbing the skin.

Medical Treatment may seek to find the cause of generalized pruritus and correct it. If no skin disease is apparent, a systemic disorder or drug-related cause may be sought.

If feasible, all drugs should be stopped or replaced with chemically unrelated drugs. Clothing that is irritating (eg, woolens) or tight should be avoided. Bathing should be brief, as it may aggravate generalized pruritus, especially if the patient has dry skin; lukewarm (not hot) water should be used. Emollients (eg, white petrolatum or other oil-based products) are good moisturizers to apply after bathing while the skin is still wet (excess water should be blotted). Caine-based anesthetics should be avoided, but lotions or creams containing 0.125% to 0.25% menthol can be useful. Ultraviolet B to the skin and oral cholestyramine can be helpful in uremia and cholestasis and at times in undiagnosed cases. Topical corticosteroids seldom alleviate generalized pruritus (without dermatitis) but may uncommonly be useful if used with lubricants in elderly patients with dry skin.

If a drug has been ruled out as the cause of pruritus, hydroxyzine (10 to 50 mg po q 4 h prn) may be prescribed or, for more severe cases, minimal and gradually increasing doses of trimeprazine or the antidepressant doxepin. If antihistamines are helpful, their sedative effect may be the reason. Antihistamines are more likely to cause intolerable side effects in the elderly. In the past decade, several newer low-sedating antihistamines have become available, including astemizole, loratadine, and cetirizine. These drugs have been used with limited success in the treatment of pruritus.

Lichen Simplex Chronicus - (Localized Scratch Dermatitis; Neurodermatitis)

A chronic, superficial, pruritic inflammation of the skin, characterized by dry, scaling, well-demarcated, hyperpigmented, lichenified plaques (thickened skin with accentuated markings) of oval, irregular, or angular shape.

Treatment - The patient should be taught that scratching and rubbing produce the skin changes. The cycle of itching and scratching must be broken. The pruritus may be controlled most effectively with topical corticosteroids; a cream may be rubbed in, or surgical tape impregnated with flurandrenolide (applied in the morning and replaced in the evening) may be preferred because it also prevents scratching. Small areas may be locally infiltrated with a long-acting corticosteroid such as triamcinolone acetonide 2.5 mg/mL (diluted with saline), 0.3 mL/cm2 of lesion; this can be repeated q 3 to 4 wk. Oral H1-blocking antihistamines or doxepin 10 mg at bedtime, increased to 25 to 50 mg/day if tolerated, may be useful.

A chronic, superficial, pruritic inflammation of the skin, characterized by dry, scaling, well-demarcated, hyperpigmented, lichenified plaques (thickened skin with accentuated markings) of oval, irregular, or angular shape.

Etiology, Symptoms, and Signs - The disease is a vicious cycle of itch begetting scratch begetting itch. Allergy appears to play no part. It affects more women than men, with onset usually between ages 20 and 50. It is rare in blacks but common in Asians and American Indians.

From prior irritation or without apparent reason, an area of skin begins to itch recurrently. The most frequently involved sites are the occiput, arms, and legs. Vigorous scratching gives only transient relief or exacerbates itch. Stress and tension increase the pruritus, and scratching may become an unconscious habit. The usual course is chronic.

Diagnosis can usually be made by inspection--a fully developed plaque has an outer zone of brownish discrete papules and a central zone of confluent papules covered with scales . Underlying causes should be excluded because generalized pruritus without apparent skin lesions may occur in patients with various systemic disorders

Treatment - The patient should be taught that scratching and rubbing produce the skin changes. The cycle of itching and scratching must be broken. The pruritus may be controlled most effectively with topical corticosteroids; a cream may be rubbed in, or surgical tape impregnated with flurandrenolide (applied in the morning and replaced in the evening) may be preferred because it also prevents scratching. Small areas may be locally infiltrated with a long-acting corticosteroid such as triamcinolone acetonide 2.5 mg/mL (diluted with saline), 0.3 mL/cm2 of lesion; this can be repeated q 3 to 4 wk. Oral H1-blocking antihistamines or doxepin 10 mg at bedtime, increased to 25 to 50 mg/day if tolerated, may be useful.
Pruritus Ani

Anal and perianal itching - The perianal skin tends to itch.

Pruritus ani has many causes: (1) dermatologic disorders (eg, psoriasis, atopic dermatitis); (2) allergic reactions (eg, contact dermatitis caused by local anesthetics, such as "-caine" preparations, various ointments, or aromatic and other chemicals used in soap) and eczema after ingestion of certain foods (especially spices, citrus fruits, vitamin C tablets, coffee, beer, and cola), although it is doubtful that true allergy is a causative agent; (3) superficial infections with fungi (eg, dermatophytosis, candidiasis) and bacteria (secondary infection caused by scratching); (4) parasites (pinworms and, less commonly, scabies or pediculosis); (5) oral antibiotics (especially tetracyclines); (6) disease processes, such as systemic diseases (eg, diabetes mellitus, liver disease), proctologic disorders (eg, skin tags, cryptitis, draining fistulas), and tumors (eg, Bowen's disease, extramammary Paget's disease); (7) hygiene, either poor with residual irritating feces or overmeticulous with excessive use of soap and rubbing; (8) warmth and hyperhidrosis caused by tight body stockings, jockey shorts, warm bed clothing, obesity, or climate; and (9) psychogenic response. Hemorrhoids usually do not cause pruritus ani (itchy rectum or itchy butt).

Skin changes may be characteristic (eg, dullness, thickening) or minimal and may be masked by excoriation caused by scratching and secondary infection. A scraping of local skin may help disclose fungal infection, and a stool sample may help find parasites.
Treatment

Because certain foods can cause pruritus ani, the effect of eliminating them from the diet should be determined. Clothing should be loose, and bed clothing light. After bowel movements, the anal area should be cleansed with absorbent cotton moistened with water. Liberal, frequent dusting with nonmedicated talcum powder helps combat moisture. Hydrocortisone acetate 1% in emulsion base, applied sparingly qid, is usually most effective. Topical fungicides (eg, amphotericin B, ciclopirox olamine cream 1%) may be used. Systemic causes and parasitic infestations must be treated specifically. Biopsies of refractory lesions can detect malignancy. X-ray treatment and surgery or injections to create permanent local anesthesia are rarely indicated.

Another View

What is pruritus ani? - Pruritus ani simply means 'itch of the anus' or 'itchy backside (butt)'. It is a very common disorder of the skin surrounding the anus. In children threadworms (pinworms) may be suspected; however, it is usually seen in adult males with considerable inner drive, often at times of stress and in hot weather when sweating is excessive.

What are the causes and aggravating factors?

It can be caused or aggravated by:

* medical problems such as eczema, threadworms, antibiotic treatment, diabetes and fungal infection
* local anal disorders such as piles, fissures and warts
* poor hygiene
* excessive sweating (e.g. due to tight clothing such as panty hose in summer)
* contact dermatitis caused by dyed or perfumed toilet tissue, soap, powders or clothing

Rules of treatment

1. Scratching - Stop-it's taboo! If you scratch at nit, wear light cotton gloves to bed.

2. Bathing - Avoid hot water. Excessive showering and scrubbing is also bad for this condition. Use a cream such as bland aqueous cream for cleaning rather than soap.

3. Drying - Keep the area as dr and cool as possible. After washing, dry gently and thoroughly with a soft towel or soft tissue: do not rub. Warm air from a hairdryer is very useful.

4. Bowel movements - Keep bowels regular and smooth by eating plenty of high-fibre foods such as bran, fresh carrots and apples. Some doctors claim that your bowel actions should be so smooth and complete that toilet paper should not be necessary.

5. Toilets - Clean gently after bowel movements. Soft paper tissue (avoid pastel tints) may be used, then clean with tufts of cottonwool with aqueous cream or bland soap and water. The best way is to use cottonwool in warm water.

6. Soaps and powder - Do not use perfumed soaps and talcum powder, including baby powder.

7. Clothing - Wear loose clothing and underwear. In men, boxer shorts should be used in preference to jockey shorts. Cottons should be used. Let the air circulate in the area. At times a skirt but no underpants (in women) is desirable. Avoid panty hose if possible.

8. Topical creams - Do not use ointments or creams unless your doctor has prescribed them. If a cream has to be us, simple creams may be the most soothing (e.g. toilet lanoline).

Seek your doctor's advice before using 'over-the-counter' prescriptions. Your doctor may prescribe a special cream.

Natural Treatments are indicated based upon the cause of the itching. These may include herbs, colon cleansing, systemic detoxification, food allergy testing or nutritional counseling, nutritional supplements, or other approaches based upon the client's status and situation. In general natural practitioners do not suggest talcum or the use of OTC or Rx because of the possibility of toxic reactions. Before undertaking any treatment always check with your health care provider.