Chronic Pruritus in the Absence of Specific Skin Disease: An Update on Pathophysiology, Diagnosis, and Therapy

Nicoletta Cassano; Gianpaolo Tessari; Gino A. Vena; Giampiero Girolomoni


Am J Clin Dermatol. 2010;11(6):399-411. 

In This Article

Diagnostic Work-up for Chronic Pruritus with Nonspecific Skin Signs

The management of pruritus with nonspecific skin signs may be difficult, time consuming, and frustrating for both the patient and the physician. Patients must be informed about the complexity of this symptom and about the likelihood of step-by-step assessments as needed. At first, the characteristics of pruritus (timing, location, severity, relieving and exacerbating factors) should be recorded and a complete physical examination aimed at excluding a dermatologic condition and detecting signs suggestive of a systemic cause should be performed. The dermatologic examination should carefully evaluate the presence of any cutaneous changes, including minimal lesions, dermographism, complications of scratching, and skin xerosis, the latter being a relevant cause or co-factor of chronic itch. A thorough medical history should be collected with emphasis on drug exposure, travel history (to exclude endemic infections), contact with environmental irritating and sensitizing substances, lifestyle (diet, substance abuse, working activity, hobbies, etc.), concomitant extracutaneous symptoms, prior hospitalizations, or recent use of volume expanders (such as hydroxyethyl starch)[20] [table III].Mental state and personality characteristics should also be investigated.

Initial laboratory investigations may include total and differential blood count, liver and renal function tests, lactate dehydrogenase, serum glucose, iron, ferritin, thyroid function tests, erythrocyte sedimentation rate, protein electrophoresis, and urinalysis. Chest x-ray, ultrasound examination of abdomen, and stool examinations for occult blood, ova, and parasites can also be considered.[21,22] Serum tumor markers are not adequate to detect an occult cancer, with the exception of prostate-specific antigens.[23] If a food additive intolerance is suspected, an elimination diet and placebo-controlled oral challenges with the food additive may be tried, but they are difficult to complete.[24]


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