Approach to Pruritus in Primary Care

Abstract

All people have pruritus even once in their lives. Acute pruritus, like insect bite, is having pruritus during a limited duration changing from seconds to weeks. Chronic pruritus is a kind of pruritus with a longer duration than 6 weeks. Chronic pruritus is a worldwide problem. It is encountered in all ages and a has great effect to quality of life. Other classifications exist other than acute or chronic pruritus. International Forum for the Study of Itch (IFSI)classifies itch into three groups: pruritus in diseased skin(group 1), pruritus in non-diseased skin(group 2), pruritus secondary to scratching lesions (group 3). Besides, it is classified into six specific groups according to the underlying disease: dermatologic, systemic, neurologic, psychogenic, mixed and others.

Keywords

• Pruritus, therapy, classification

Birinci Basamakta Pruritusa Yaklaşım

Abstract

Tüm insanlar hayatlarında bir kez de olsa pruritusu yaşamışlardır. Akut kaşıntı, böcek ısırması gibi, saniyelerden haftaya kadar değişen sınırlı süre kaşıntı yaşanmasıyken, kronik kaşıntı ise 6 haftadan uzun kaşıntılara verilen addır. Kronik pruritus dünya genelinde bir problemdir. Her yaşta görülebilir ve yaşam kalitesine büyük etkisi vardır. Kaşıntı için akut ve kronikten başka sınıflamalar da vardır. IFSI (International Forum for the Study of Itch: Kaşıntı Çalışması Uluslararası Forumu)  sınıflaması kaşıntılı bireyleri 3 gruba ayırır; hastalıklı deride kaşıntısı olanlar (grup 1), hastalık olmayan deride kaşıntısı olanlar (grup 2), deri kaşıma lezyonlarına sekonder kaşıntısı olanlar (grup 3). Ayrıca altta yatan kaşıntılı hastalıklara göre de 6 spesifik kategoriye ayırır: dermatolojik, sistemik, nörolojik, psikojenik, miks ve diğer pruritus.

Keywords

• kaşıntı, tedavi, sınıflandırma

References

1. Stander S, Weisshaar E, Mettang T, et al. Clinical classification of itch: a position paper of the International Forum for the Study of Itch. Acta Derm Venereol 2007;87:291–4.
2. Savin JA. How should we define itching? JAAD 1998;39:268–9.
3. Zucker I, Yosipovitch G, David M, Gafter U, Boner G. Prevalence and characterization of uremic pruritus in patients undergoing hemodialysis: uremic pruritus is still a major problem for patients with end-stage renal disease. J Am Acad Dermatol 2003; 49:842–6.
4. Mettang T, Pauli-Magnus C, Alscher DM. Uraemic pruritus – new perspectives and insights from recent trials. Nephrol Dial Transplant 2002;17:1558–63.
5. Talwalkar JA, Souto E, Jorgensen RA, Lindor KD. Natural history of pruritus in primary biliary cirrhosis. Clin Gastroenterol Hepatol 2003;1:297–302.
6. Yosipovitch G, David M. The diagnostic and therapeutic approach to idiopathic generalized pruritus. Int J Dermatol 1999;38:881-7.
7. Zirwas MJ, Seraly MP. Pruritus of unknown origin: a retrospective study. J Am Acad Dermatol 2001;45:892- 6.
8. Etter L, Myers SA. Pruritus in systemic disease: mechanisms and management. Dermatol Clin 2002;20:459- 72.

9. Krajnik M, Zylicz Z. Understanding pruritus in systemic disease. J Pain Symptom Manage. 2001;21:151-68.
10. Moses S. Pruritus. Am Fam Physician. 2003;68:1135-42.
11. Faye O, Cisse L, Berthe S, Dicko A, Ndiaye HT, Traore P. Pruritus in dermatological hospital in Bamako, Mali. International Journal of Dermatology 2012;51 (Suppl. 1):44–7.
12. Weisshaar E, Szepietowski JC, Darsow U, Misery L, Wal- lengren J, Mettang T, et al. European Guideline on Chronic Pruritus. Acta Derm Venereol 2012;92:563–81
13. Kretzmer GE, Gelkopf M, Kretzmer G, Melamed Y. Idiopathic pruritus in psychiatric inpatients: an explorative study. Gen Hosp Psychiatry 2008;30:344-8.
14. Mazeh D, Melamed Y, Cholostoy A, Aharonovitzch V, Weizman A, Yosipovitch G. Itching in the psychiatric ward. Acta Derm Venereol 2008;88:128-31.
15. Ferm I, Sterner M, Wallengren J. Somatic and psychiatric comorbidity in patients with chronic pruritus. Acta Derm Venereol 2010;90:395-400.
16. Amaro P, Nunes A, Maçôas F, Ministro P, Baranda J, Cipriano A, et al. Ticlopidine-induced prolonged cholestasis: a case report. Eur J Gastroenterol Hepatol 1999;11:673–6.
17. Hunt CM, Washington K. Tetracycline-induced bile duct paucity and prolonged cholestasis. Gastroenterology 1994;107:1844–7.
18. Mikhail NE. Methimazole-induced cholestatic jaundice. South Med J 2004;97:178–82.
19. Nammour FE, Fayad NF, Peikin SR. Metformin-induced cholestatic hepatitis. Endocr Pract 2003; 9: 307–9.
20. Quattropani C, Schneider M, Helbling A, Zimmermann A, Krahenbuhl S. Cholangiopathy after short-term administration of piperacillin and imipenem/cilastatin. Liver 2001;21:213–6.
21. Ständer S, Streit M, Darsow U, Niemeier V, Vogelgsang M, Ständer H et al. Diagnostisches und therapeutisches Vorgehen bei chronischem Pruritus. J Dtsch Dermatol Ges 2006;4:350–70.
22. Shirin H, Schapiro JM, Arber N, Pinkhas J, Sidi Y, Salomon F. Erythromycin base-induced rash and liver function disturbances. Ann Pharmacother 1992;26:1522–3.
23. Orme S, da Costa D. Generalized pruritus associated with amlodipine. Br Med J 1997; 315: 463.
24. Odeh M, Oliven A. Verapamil-associated liver injury. Harefuah 1998;134:36–7.
25. Kowdley KV, Keeffe EB, Fawaz KA. Prolonged cholestasis due to trimethoprim sulfamethoxazole. Gastroenterology 1992;102:2148–50.
26. Larrey D, Amouyal G, Pessayre D, Degott C, Danne O, Machayekhi JP. Amitriptyline-induced prolonged cholestasis. Gastroenterology 1988;94:200–3.
27. Metze D, Reimann S, Szépfalusi Z, Bohle B, Kraft D, Luger TA. Persistent pruritus after hydroxyethyl starch infusion therapy: a result of long-term storage in cutaneous nerves. Br J Dermatol 1997;136:553–9.
28. Millikan LE. Treating pruritus. What’s new in safe relief of symptoms? Postgrad Med 1996;99:173-6, 179- 84.
29. Yosipovitch G. Pruritus. An Update. Curr Probl Dermato. 2003;15:135–64.
30. Black MM. Polymrophic eruption of pregnancy. In: Black M, McKay M, et al, editors. Obstetric and gynecologic dermatology. St Louis: Mosby;2002:39-44.
31. Charlesworth EN, Beltrani VS. Pruritic dermatoses: overview of etiology and therapy. Am J Med 2002;113(suppl 9A):25-33.
32. Reamy BV. A Diagnostic Approach to Pruritus. Am Fam Physician 2011;84:195-202.
33. Meltem Önder. Pruritus. Tüzün Y,Gürer MA, Serdaroğlu S, Oğuz O, Aksungur VL(editörler). Dermatoloji 3. baskı. İstanbul: Nobel Yayınları;2008:171.
34. Brunner W. Pruritus – auch eine internistische Herausforderung. Schweiz Med Wochenschr 1995;125:2244– 50.
35. Massey EW, Pleet AB. Localized pruritus-notalgia paresthetica. Arch Dermatol. 1979;115:982-3.
36. Veien NK, Hattel T, Laurberg G, Spaun E.. Brachioradial pruritus. J Am Acad Dermatol 2001;44:704-705.
37. Wallengren J, Sundler F. Brachioradial pruritus is associated with a reduction in cutaneous innervation that normalizes during symptom-free remissions. J Am Acad Dermatol 2005;52:142-5.
38. Barry R, Rogers S. Brachioradial pruritus—an enigmatic entity. Clin Exp Dermatol 2004;29:637-8.
39. Cohen AD, Masalha R, Medvedovsky E, Vardy DA.. Brachioradial pruritus: a symptom of neuropathy. J Am Acad Dermatol 2003;48:825-8.
40. Wallengren J. Brachioradial pruritus: a recurrent solar dermopathy. J Am Acad Dermatol 1998;39(5, pt 1):803-6.
41. Lacy BE, Weiser K. Common anorectal disorders: diagnosis and treatment. Curr Gastroenterol Rep 2009;11:413-9.
42. Kuehn HG, Gebbensleben O, Hilger Y, Rohde H. Relationship between anal symptoms and anal findings. Int J Med Sci 2009;6:77-84.
43. Fargo MV, Latimer KM. Evaluation and Management of Common Anorectal Conditions. American Family Physician 2012;85:624-30.
44. Patel T, Yosipovitch G. Therapy of Pruritus. Expert Opin Pharmacother 2010;11:1673–1682.
45. Hon KL, Lam MC, Leung TF, Chow CM, Wong E, Leung AK. Assessing itch in children with atopic dermatitis treated with tacrolimus: objective versus subjective assessment. Adv Ther 2007;24:23–8.
46. Kaufmann R, Bieber T, Helgesen AL, Andersen BL, Luger T, Poulin Y. Onset of pruritus relief with pimecrolimus cream 1% in adult patients with atopic dermatitis: a randomized trial. Allergy 2006;61:375–81.
47. Stander S, Schurmeyer-Horst F, Luger TA, Weisshaar E. Treatment of pruritic diseases with topical calcineurin inhibitors. Ther Clin Risk Manag 2006;2:213–8
48. Stander S, Luger T, Metze D. Treatment of prurigo nodularis with topical capsaicin. J Am Acad Dermatol 2001;44:471–8.
49. Leibsohn E. Treatment of notalgia paresthetica with capsaicin. Cutis 1992;49:335–6.
50. Breneman DL, Cardone JS, Blumsack RF, Lather RM, Searle EA, Pollack VE. Topical capsaicin for treatment of hemodialysisrelated pruritus. J Am Acad Dermatol 1992;26:91–4.
51. Goodless DR, Eaglstein WH. Brachioradial pruritus: treatment with topical capsaicin. J Am Acad Dermatol 1993;29:783–4.
52. Lotti T, Teofoli P, Tsampau D. Treatment of aquagenic pruritus with topical capsaicin cream. J Am Acad Dermatol 1994;30:232–5.
53. Szepietowski JC, Szepietowski T, Reich A. Efficacy and tolerance of the cream containing structured physiological lipids with endocannabinoids in the treatment of uremic pruritus: a preliminary study. Acta Dermatovenerol Croat 2005;13:97–103.
54. Eberlein B, Eicke C, Reinhardt HW, Ring J. Adjuvant treatment of atopic eczema: assessment of an emollient containing N-palmitoylethanolamine (ATOPA study). J Eur Acad Dermatol Venereol 2008;22:73– 82.
55. Stander S, Reinhardt HW, Luger TA. Topical cannabinoid agonists. An effective new possibility for treating chronic pruritus. Hautarzt 2006;57:801–7.
56. Patel T, Ishiuji Y, Yosipovitch G. Nocturnal itch: why do we itch at night? Acta Derm Venereol 2007;87:295–8.
57. Davis MP, Frandsen JL, Walsh D, Andresen S, Taylor S. Mirtazapine for pruritus. J Pain Symptom Manage 2003;25:288–91.
58. Hundley JL, Yosipovitch G. Mirtazapine for reducing nocturnal itch in patients with chronic pruritus: a pilot study. J Am Acad Dermatol 2004;50:889–91.
59. Demierre MF, Taverna J. Mirtazapine and gabapentin for reducing pruritus in cutaneous T-cell lymphoma. J Am Acad Dermatol 2006;55:543–4.
60. Stander S, Bockenholt B, Schurmeyer-Horst F, Weishaupt C, Heuft G, Luger TA et al. Treatment of chronic pruritus with the selective serotonin re-uptake inhibitors paroxetine and fluvoxamine: results of an open- labelled, two-arm proof-of-concept study. Acta Derm Venereol 2009;89:45–51.
61. Mayo MJ, Handem I, Saldana S, Jacobe H, Getachew Y, Rush AJ. Sertraline as a first-line treatment for cholestatic pruritus. Hepatology 2007;45:666–74.
62. Mansour-Ghanaei F, Taheri A, Froutan H, Ghofrani H, Nasiri-Toosi M, Bagherzadeh AH. Effect of oral naltrexone on pruritus in cholestatic patients. World J Gastroenterol 2006; 12: 1125–8.
63. Malekzad F, Arbabi M, Mohtasham N Toosi P, Jaberian M, Mohajer M, et al. Efficacy of oral naltrexone on pruritus in atopic eczema: a double-blind, placebo-controlled study. J Eur Acad Dermatol Venereol 2009;23:948–50.
64. Jung SI, Seo CH, Jang K, Ham BJ, Choi IG, Kim JH et al. Efficacy of naltrexone in the treatment of chronic refractory itching in burn patients: preliminary report of an open trial. J Burn Care Res 2009;30:257–60.
65. Peer G, Kivity S, Agami O, Fireman E, Silverberg D, Blum M et al. Randomised crossover trial of naltrexone in uraemic pruritus. Lancet 1996;348:1552–4.
66. Bergasa NV, Alling DW, Talbot TL, Wells MC, Jones EA. Oral nalmefene therapy reduces scratching activity due to the pruritus of cholestasis: a controlled study. J Am Acad Dermatol 1999; 41: 431–4.
67. Monroe EW. Efficacy and safety of nalmefene in patients with severe pruritus caused by chronic urticaria and atopic dermatitis. J Am Acad Dermatol 1989;21:135–6.
68. Kanitakis J. Brachioradial pruritus: report of a new case responding to gabapentin. Eur J Dermatol 2006;16:311–2.
69. Loosemore MP, Bordeaux JS, Bernhard JD. Gabapentin treatment for notalgia paresthetica, a common isolated peripheral sensory neuropathy. J Eur Acad Dermatol Venereol 2007;21:1440–1.
70. Gunal AI, Ozalp G, Yoldas TK, Gunal SY, Kirciman E, Celiker H. Gabapentin therapy for pruritus in haemodialysis patients: a randomized, placebo-controlled, double-blind trial. Nephrol Dial Transplant 2004;19:3137–9.
71. Demierre MF, Taverna J. Mirtazapine and gabapentin for reducing pruritus in cutaneous T-cell lymphoma. J Am Acad Dermatol 2006;55:543–4.