37. Itch Flashcards
History taking PC: itch
HoPC: timing, severity, location, crawling sensation? Prickling sensation? Burning? Relieving factors?
Red flags: weight loss, night sweats, fatigue, fever, lumps
Nocturnal itch may suggest
MHx: any skin problems, any liver problems, any kidney problems
DHx:
FHx: haematological cancers?, autoimmune problems, atopy?
SHx: alcohol (liver), living conditions, anyone else got an itch?, stress
ICE: impact on persons life and mental wellbeing/confidence
Examination: itch
General: skin colour (jaundiced?plethroic?), skin lesions, scratch marks, pattern of rash?, signs of iron deficiency anaemia? weight loss? weight gain?
Lymph nodes: lymphadenopathy?
surgical sieve PC:itch
Vascular
Immune/infectious: scabies, eczema, psoriasis
Trauma:
Autoimmune: urticaria, thyroid, diabetes
Metabolic: liver pathology, renal failure, cholestasis, iron deficiency anaemia
Iatrogenic: drugs?
Neoplastic: lymphoma, polycythaemia vera
Congenital: liver problem?
Degenerative:
Environment: allergic to cosmetic
Functional: prolonged itch,
Psychiatric: parasitosis,
Pregnancy:
Topical:
Infection : scabies
Immune : eczema, psoriasis, urticaria
Allergy: contact dermatitis, allergic to cosmetic
Systemic:
- metabolic: diabetes, iron deficiency anaemia, allergy to drug
- autoimmune : thyroid pathology
- organ: liver failure, cholestasis, renal failure
- neoplastic : lymphoma, polycythaemia Vera
Functional : prolonged itch
Psychiatry : parasitosis
Pregnancy: liver things
Plan invetsigation widespread itch with no rash?
Skin:
Inflammatory markers such as ESR and/or CRP
Systemic:
Liver: LFTs, viral hepatitis serology
Metabolic: FBC, U&E, iron studies, TFTs, HbA1c
Neoplastic: FBC, blood film, bone chemistry
CXR
Pregnancy: pregnancy test
severe itch with skin marks and scratch marks present for 2 weeks and getting worse, itch worse at night time- impacting sleep,
scabies
typical history and examination scabies
PC: severe itch with skin marks and scratch marks present for 2 weeks and getting worse
HoPC: itch worse at night time- impacting sleep,
Red flags: no fever, no weight loss, some fatigue but thinks this is due to reduced sleep due to itch, no night sweats, no lumps
MHx: none
DHx: none
Allergies: nkda
FHx: none
SHx: 1st year at uni, new sexual partner also experiencing severe itch
ICE: sleep is severely affected and is affecting uni work, skin marks affecting confidence, concerned it is infectious as her partner is having the same problem - is embarrassed to talk to anyone about it
o/e: Widespread erythematous papules on fingers, front of torso, genitalia, extensor surfaces of arms, scratch marks, thread-like tracks measuring around 5–10 mm in between fingers,
pathophysiology scabies
Scabies is a transmissible skin disease caused by the ectoparasitic mite Sarcoptes scabiei var. Hominis.
Itch is due to a delayed type-IV hypersensitivity reaction to the mite and mite products (faeces and eggs) so symptoms appear 4-6 weeks after infection.
Plan ?scabies
Management:
Permethrin 5% cream
Inform close contacts
Wash bedding and clothes at 60 degrees
typical history urticaria
PC: widespread rash that came up yesterday
HoPC: itchy, burning sensation
Red flags: no throat swelling, no difficulty breathing, has an epi-pen on her,
MHx: asthma, current URTI, has been taking ibuprofen as feels rubbish, has had this type of rash in the past
DHx: blue inhaler, brown inhaler
Allergies: egg
SH: none
ICE:
o/e: widespread areas of raised patchy skin swelling (weals)
triggers urticaria
classic allergy: food allergy, bee sting, contact urticaria-rubber latex
infection:acute infection
drugs: antibiotics, NSAIDs, vaccination, radiocontrast,
plan ?urticaria
Management:
non-sedating antihistamines are first-line eg: cetirizine, loratadine, and fexofenadine
prednisolone is used for severe or resistant episodes
In children: cetirizine
pathophysiology urticaria
type 1 hypersensitivity
Weals are due to release of chemical mediators from tissue mast cells and circulating basophils. These chemical mediators include histamine, platelet-activating factor and cytokines. The mediators activate sensory nerves and cause dilation of blood vessels and leakage of fluid into surrounding tissues. Bradykinin release causes angioedema.
typical history polycythaemia vera
PC: Pruritus particularly after warm bath
HoPC:
Red flags: fatigue, weight loss, night sweats, fever
MHx: previous DVT, previous stroke,
DHx:
FHx:
SHx:
ICE:
o/e: ruddy complexion, splenomegaly
pathophysiology polycythaemia vera
uncontrolled proliferation of a single type of stem cell: in PV this is erythroid cells
plan ?polycythaemia vera
Investigation:
diagnosis: JAK2 + raised haematocrit or if not JAK2 more complicated
bloods:
FBC - inc haematocrit (high)
Ferritin - low in primary, normal in secondary
JAK2 mutation
U&E, LFTs
Management:
- aspirin: reduces the risk of thrombotic events
- venesection (first-line treatment to keep the haemoglobin in the normal range)
- chemotherapy (hydroxyurea - slight increased risk of secondary leukaemia, phosphorus-32 therapy)
complications polycythaemia vera
can lead to secondarily myelofibrosis or acute myeloid leukemia
typical history atopic dermatitis
PC: rash, general dry skin, itchiness in flexures. In infants=face and trunk, in slightly older = extensor surfaces, >4 in flexures
HoPC:
Red flags:
Environment: triggers: irritants eg soaps, detergents, food allergy (particularly in children), house dust mites, pollens, pets, stress, hormonal changes
MHx:
DHx:
Allergies:
FHx: family history of atopy. Genetic mutations affecting production of filaggrin
SHx:
ICE:
plan ?atopic dermatitis
Emollient 500g/week for an adult, 250g/week for a child
Steroid ladder (mild if face) HEAD Hydrocortisone, Eumovate, Betnovate, Dermovate
name 2 thin emollients and 2 thick emollients
thin:
Diprobase cream
cetraben cream
E45
Aveeno
thick:
diprobase ointment
cetraben ointment
typical history contact dermatitis
PC: dermatitis following direct skin contact with irritant - most commonly on the hands
HoPC:
Red flags:
Environment: work involves irritants, new job
MHx: none, no atopy
DHx:
Allergies:
FHx:
SHx:
ICE:
plan ?contact dermatitis
Avoid irritant
Emollient
Steroid
inflamed greasy areas with fine scaling, locations: beard area, nasolabial folds, eyelashes/eyebrows, behind ear, scalp
seborrhoeic dermatitis
typical history seborrhoeic dermatitis
PC: inflamed greasy areas with fine scaling, locations: beard area, nasolabial folds, eyelashes/eyebrows, behind ear, scalp
HoPC:
Red flags:
Environment: change of season, stress,
MHx: may have HIV or recent illness,
DHx: certain medications eg buspirone, chlorpromazine, cimetidine, griseofulvin, haloperidol, lithium, interferon alfa and methyldopa
Allergies:
FHx:
SHx:
pathophysiology seborrhoeic dermatitis
affects areas rich in sebaceous glands (microscopic glands found in your hair follicles that secrete sebum) so is most common on face, scalp and chest. Inflammatory reaction to yeast called malassezie spp.
plan ?seborrhoeic dermatitis
Investigation:
1. Consider HIV testing
Management
Adults
+ Non-greasy emollient soaps
+ Olive oil leave on and rub scales off
1. Ketoconazole 2% shampoo or cream depending on area
Children
+ Non-greasy emollient soaps
+ Olive oil leave on and rub scales off
1. A topical imidazole cream (clotrimazole 1% or miconazole 2%)
larger plaques, elbows, knees and lower back, and scalp. silvery scale. Kobhner phenomenon- new plaques at sites of skin trauma
Chronic plaque psoriasis
widespread small papules/plaques, trunk and limbs
Guttate psoriasis
redness in body folds/genitals
?flexural psoriasis
what are the psoriasis nail signs
pitting, onycholysis, arthritis
Typical history psoriasis
Chronic plaque psoriasis: larger plaques, elbows, knees and lower back, and scalp. silvery scale. Kobhner phenomenon- new plaques at sites of skin trauma
Guttate psoriasis: widespread small papules/plaques, trunk and limbs
Flexural psoriasis: affects body fold and genitals
HoPC:
Red flags:
Environment: stress, skin trauma,
MHx: recent strep throat in guttate psoriasis
DHx: lithium
FHx:
SHx:
ICE:
o/e: nail signs: pitting, onycholysis, arthritis
genetic associations psoriasis
HLA-B13, -B17, and -Cw6.
General management psoriasis
+ Improved by sunlight
+ Regular emollients
- Potent corticosteroid once daily and vitamin d analogue once daily (separate times) for up to 4 weeks
- Vitamin d analogue twice daily for 8 weeks
- Potent corticosteroid twice daily for 4 weeks or coal tar prep applied once or twice daily
Secondary care management:
Phototherapy UVB 3x per week
Methotrexate
Management scalp psoriasis
- Potent corticosteroid once daily for 4 weeks
- Different formulation
Management face/flexural/genital psoriasis
- Mild/moderate potency corticosteroid once or twice daily for maximum 2 weeks
Time limits on topical steroid use?
- Potent steroids no longer than 8 weeks at a time
- Very potent corticosteroids for no longer than 4 weeks at a time
NICE recommend that we aim for a 4-week break before starting another course of topical corticosteroids
when may topical steroids cause systemic effects?
systemic side-effects may be seen when potent corticosteroids are used on large areas e.g. > 10% of the body surface area
limits on corticosteroids face/flexures/genitals
no more than 2 weeks in a month
side effects of topical corticosteroids
skin atrophy
striae
rebound symptoms - burning, redness, and itchy skin. Steroid cream withdrawal symptoms may be worse than the skin condition you were taking the steroids to treat.
Examples of vitamin D analogues
calcipotriol (Dovonex), calcitriol and tacalcitol
how do topical vitamin D analogues work
they work by ↓ cell division and differentiation → ↓ epidermal proliferation
they tend to reduce the scale and thickness of plaques but not the erythema
Restrictions on topical vit D analogues
they should be avoided in pregnancy
the maximum weekly amount for adults is 100g
rapidly developing widespread erythema, followed by the eruption of white, sterile non-follicular pustules which coalesce to form large lakes of pus.
pustular psoraisis
emergency same day derm appt
diffuse, widespread severe psoriasis that affects more than 90% of the body surface area
erythrodermic psoriasis
emergency same day derm appt
what is lichen planus
autoimmune skin codnition
itchy, papular rash most common on the palms, soles, genitalia, oral mucosa and flexor surfaces of arms
rash often polygonal in shape, with a ‘white-lines’ pattern on the surface (Wickham’s striae)
pattern of lichen planus
palms, soles, genitalia and flexor surfaces of arms, oral involvement
what can cause lichenoid drug eruption
gold
quinine
thiazides
management of lichen planus
potent topical steroids are the mainstay of treatment
benzydamine mouthwash or spray is recommended for oral lichen planus
extensive lichen planus may require oral steroids or immunosuppression
causes pruritus ani
Idiopathic
Secondary to
Skin conditions
Infection eg threadworms
Rectal and anal pathology
Systemic causes of itch
approach to pruritus ani
assessment
hx as any other itch
examine area and skin for skin conditions
invgn
swab
lower GI invgn if suspected
skin biosy if suspected
if symptoms dont settle, blood tests for itch eg FBC, ferritin etc.
PC threadworms
usually children
perianal itching, particularly at night
girls may have vulval symptoms
management threadworms
mebendazole is used first-line for children > 6 months old. A single dose is given unless infestation persists. for all members of the household
hygiene measures
causes of pruritis vulvae
irritant contact dermatitis (e.g. latex condoms, lubricants): most common cause
atopic dermatitis
seborrhoeic dermatitis
lichen planus
lichen sclerosus
psoriasis: seen in around a third of patients with psoriasis
most common cause pruritis vulvae
irritant contact dermatitis (e.g. latex condoms, lubricants)
general advice pruritus vulvae
In relation to washing:
avoid baths, shower instead only 1ce a day
clean w emollient such as epaderm
what is lichen sclerosus
Lichen sclerosus is a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis.
symptoms lichen sclerosus
Itching
Soreness and pain possibly worse at night
Skin tightness
Painful sex (superficial dyspareunia)
Erosions
Fissures
The Koebner phenomenon
o/e lichen sclerosus
“Porcelain-white” in colour
Shiny
Tight
Thin
Slightly raised
There may be papules or plaques
managenment lichen sclerosus
Potent topical steroids
usually clobetasol propionate 0.05% (dermovate)
complication lichen sclerosus
5% risk of developing squamous cell carcinoma of the vulva.
what are varicose veins
Varicose veins are dilated, tortuous, superficial veins that occur secondary to incompetent venous valves, allowing blood to flow back, away from the heart.
reflux in what veins are most common varicose veins
reflux in the great saphenous vein and small saphenous vein
risk factors varicose veins
increasing age
female gender
pregnancy - the uterus causes compression of the pelvic veins
obesity
presentation varicose veins
PC: cosmetic issue
PC symptomatic: aching, throbbing, itching
PC: a complication of varicose veins
complications of varicose veins
varicose eczema (also known as venous stasis)
haemosiderin deposition → hyperpigmentation
lipodermatosclerosis → hard/tight skin
atrophie blanche → hypopigmentation
bleeding
superficial thrombophlebitis
venous ulceration
deep vein thrombosis
invetsigation varicose veins
venous duplex ultrasound: this will demonstrate retrograde venous flow
management of varicose veins
mainly conservative:
leg elevation
weight loss
regular exercise
graduated compression stockings
if meet criteria for secondary care:
endothermal ablation
foam sclerotherapy
surgery
reasons for rf to secondary care - varicose veins
symptomatic:
significant/troublesome lower limb symptoms e.g. pain, discomfort or swelling
complication:
skin changes secondary to chronic venous insufficiency (e.g. pigmentation and eczema)
superficial thrombophlebitis
an active or healed venous leg ulcer
previous bleeding from varicose veins
