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Andrews Diseases Of Skin > Chapter 4: Pruritus and Neurocutaneous Dermatoses > Flashcards

Chapter 4: Pruritus and Neurocutaneous Dermatoses Flashcards

1
Q

What percentage of of the afferent unmyelinated C neurons respond to pruritogenic stimuli

A

5%

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2
Q

How are itch sensations in the sub epidermal area transmitted to the CNS

A

via the lateral spinothalamic tract

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3
Q

What are the most important itch mediators

A 
histamine
Serotonin
tryptate
opioid peptides
Substance P
Prostaglandins such as PGE 2
acetylcholine
Cytokines such as IL-2
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4
Q

What are the 4 categories of itch

A

pruritoceptive
itch caused by systemic disorders
neuropathic itch
psychogenic itch

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5
Q

how is heat associated with pre existing pruritus

A

heat aggravates preexisting itch

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6
Q

What is pruritoceptive itch

A

itch induced by skin disorders

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7
Q

What conditions are associated with a pleasure of scratching that is so intense that the patient - despite the realization that he is damaging the skin - is often unable to stop short of inflicting damage

A 
lichen simplex chronicus
atopic dermatitis
numeral eczema
dermatitis herpetiformis
neurotic excoriations
eosinophilic folliculitis
uremic pruritus
subacute prurigo
paraneoplastic itch
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8
Q

What is the treatment for the itchy patient

A

Keeping cool and avoidance of hot showers

Topical remedies that include menthol and camphor
Capsaicin

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9
Q

What is the problem with using topical steroids or calcineurin inhibitors for itch

A

Their effect is to decrease itching via their anti-inflammatory action, and therefor are of limited efficacy in neurogenic, psychogenic and systemic disease related pruritus.

Only beneficial for pruritoceptive cases

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10
Q

What oral medications are beneficial for pruritus

A

H1 blockers help with nocturnal itching. Overall limited benefit

Doxepin (TCA) reduces anxiety and depression , and has utility in several pruritic disorders

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11
Q

What effect does the opioid receptor have on itch

A

M-opioid receptors stimulate itch

K-opioid receptors inhibit itch perception.

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12
Q

What are the most common internal causes of itch

A

liver disease (obstructive hepatitis C
Renal failure
hypo and hyperthyroidism
hematopoietic diseases

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13
Q

How will pruritus of Hodgkin disease present

A

usually presents as a continuous itch, and at times accompanied by severe burning.

incidence of 10-30%

7% will have pruritus as initial presentation

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14
Q

What is the most common systemic cause of pruritus

A

CKD (Chronic Kidney Disease).

Pruritus effects 20-80% of patients with CKD

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15
Q

What treatment is beneficial for pruritus associated with CKD

A

UVB phototherapy, but often recurs after discontinuation.

100mg Neurontin given after each dialysis session may be beneficial

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16
Q

How is itch triggered in patients with obstructive liver disease

A

20-50% of patients with obstructive jaundice have pruritus.

Itch is likely central triggered as suggested by elevated CNS opioid peptide levels, down regulation of opioid peptide receptors.

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17
Q

Who is effected by Primary Biliary Cirrhosis?

A

Women over the age of 30

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18
Q

What percentage of patients with PBC will have pruritus

A

80%

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19
Q

How is the pigment of the skin effected by PBC

A

Jaundice and a striking melanotic hyperpigmentation of the entire skin; the patient may turn almost black, except for a hypo pigmented “butterfly” area in the upper back.

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20
Q

What findings are associated with PBC

A

Dark urine
steatorrhea
Osteoporosis
Positive Antimitochondrial Antibody

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21
Q

What treatment of pruritus in PBC has shown benefit

A

Naltrexone has shown benefit, but has many side effects

Colestyramine: 4grams 1-3 times daily
UVB: Twice weekly
Rifampin: 300-450 daily

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22
Q

What induces pruritus in polycythemia vera

A

temperature changes or hot showers

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23
Q

What treatment may relieve pruritus in polycythemia vera

A

aspirin

PUVA and narrow band UVB

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24
Q

What is winters itch

A

Asteatotic eczema or xerotic eczema.

Characterized by pruritus that usually first manifests and is most severe on the legs and arms. May develop into eczema craquele

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25
Q

What is eczema craquele

A

fine cracks in the eczematous area that resemble the cracks in old porcelain dishes

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26
Q

What is the treatment for winter itch

A

For more severe symptoms utilize the “soak and smear”

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27
Q

What is a “soak and smear”

A

Patient soaks in a tub of plain water at a comfortable temperature for 20 minutes prior to bedtime. Immediately on exiting the tub, without drying, triamcinolone, 0.025-0.1% ointment is applied to the wet skin.

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28
Q

Pruritus Ani

A

Centered on the anal or genital area with little or no pruritus elsewhere.

  • allergic contact dermatitis (toilet paper)
  • irritant contact dermatitis (gastric content)
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29
Q

mycotic pruritus ani

A

characterized by fissures and a white sodden epidermis.

  • Candida albicans, Epidermophyton, floccosum, and trichophyton rubrum are frequent causative agents.
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30
Q

What is the treatment of pruritus ani

A

cleansing with wet toilet tissue. Medicated cleansing pads should be used regularly

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31
Q

Addicted scrotum syndrome

A

use of high potency steroids in chronic use for treatment of pruritus scroti

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32
Q

What is the treatment of pruritus scroti?

A

Tacrolimus is useful to avoid steroid side effects

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33
Q

Pruritus vulvae

A

Contact dermatitis from sanitary pads, contraceptive douche solutions, fragrance … partners condom may account for vulvar pruritus

Lichen sclerosus is another frequent cause of pruritus in the genital area.

34
Q

What is the treatment for lichen sclerosus

A

pulsed dosing of high potency topical steroids to to topical tacrolimus or pimecrolimus

35
Q

What is puncta pruritica

A

Itchy points

consists of one or two itchy spots in clinically normal skin.

May be a variant of nostalgia paresthetica

36
Q

What is aquagenic pruritus

A

Degranulation of mast cells and increased concentration of histamine and acetylcholine in the skin after contact with water

37
Q

What is aquadynia

A

a variant of aquagenic pruritus where widespread burning is noted 15 - 45 minutes after water exposure

Treat with clonidine or propranolol

38
Q

What is the treatment of aquagenic pruritus

A

antihistamines
systemic steroids
sodium bicarbonate dissolved in bath water
propranolol
naltrexone
UVB or psoralen + UVA (PUVA) phototherapy

39
Q

What is the treatment for scalp pruritus

A

Topical tar shampoo
salicylic acid shampoos
corticosteroid topical (gels, mousse, shampoo)

Low dose antidepressant such as doxepin

40
Q

What is the term for chronic itchy idiopathic dermatosis

A

prurigo simplex

41
Q

What is the characteristic lesion of prurigo

A

a dome shaped papule topped with a vesicle ; the vesicle is usually present only transiently because of its immediate removal by scratching.

42
Q

What is the treatment of prurigo simplex

A

topical corticosteroids, and oral antihistamines

43
Q

What is prurigo pigmentosa

A

a rare dermatosis of unknown cause characterized by the sudden onset of erythematous papule or vesicles that leave reticulated hyperpigementation when they heal.

Mainly affects japanese, rarely white persons

Men outnumber women 2:1

Mean age of onset is 25

Affects upper back, nape, clavicular region and chest

44
Q

What is the treatment for prurigo pigmentosa

A

minocycline 100mg qd or BID

Dapsone and alteration of diet are effective, but topical steroids are not.

45
Q

Papuloerthroderma of ofuji

A

a rare disorder most commonly found in Japan.

pruritic papule that spare the skin folds, producing bands of uninvolved cutis, the so-called deck-chair sign

May be a paraneoplasitic syndrome

46
Q

LSC

A

Lichen simplex chronicus

Also known as circumscribed neurodermatitis

Results from long-continued rubbing and scratching

47
Q

What is the clinical presentation of LSC

A

Exagerated skin markings, striae form criss cross patterns.

Flat-topped, shiny, smooth, quadrilateral facets known as lichenification

Often associated with stress and anxiety

48
Q

What is the treatment of LSC

A

Strong steroids initially, but not indefinitely
Clobetasol propionate
Betamethasone dipropionate

Topical doxepin, capsaicin or pimecrolimus/tacrolimus

5-10mg/ml kenalog may be used

49
Q

What is prurigo nodularis

A

itching nodules situated chiefly on the extremities, especially on the anterior surfaces of the thighs and legs

50
Q

What is russels sign

A

Crusted papules on the dorsal of the dominant hand from cuts by the feet. Associated with bulimia and self induced vomiting

51
Q

What is the matchbox sign

A

Samples of alleged parasites enclosed in assorted containers, paper tissue or sandwiched between adhesive tape

52
Q

What is Morgellons disease

A

Considered by many to be another name for delusional parasitosis.

53
Q

What is the mainstay of treatment for delusional parasitosis

A

Newer atypical antipsychotic agents, such as:
Risperidone
Olanzapine

Have fewer side effects and are now considered the appropriate first line agents

54
Q

What are neurotic excoriations

A

unconscious compulsive habits of picking , tendency may be so persistent and pronounced that excoriations of the skin are produced

55
Q

What is the treatment for neurotic excoriations

A

doxepin

  • has antipruritic and antidepressant effects
  • doses are slowly increased to 100mg or higher
56
Q

What is factitious dermatitis

A

Dermatitis artefacta
- self inflicted skin lesions made consciously and often with the intent to elicit sympathy, escape responsibilities, or collect disability insurance

neck and shoulder crepitation is also a complication in manic patients that results from hyperventilation and breath-holding

57
Q

Trichotillomania

A

aka trichotillosis or neuromechanical alopecia

a neurosis characterized by an abnormal urge to pull out the hair

  • irregular areas of hair loss
  • Hairs are broken and show differences in length.
  • Often associated with onychophagy (nail biting)
58
Q

What is the “Friar Tuck” Sign?

A

Classic presentation of trichotillomania

vertex and crown alopecia

Hairs are broken and show differences in length.

59
Q

What is dermatothlasia

A

a cutaneous neurosis characterized by a patients uncontrollable desire to rub or pinch themselves to form a bruised area on the skin

60
Q

What is bromidrosiphobia?

A

a monosymptomatic delusional state in which a person is convinced that his or her sweat has a repugnant odor that keeps other people away

  • may be an early symptom of schizophrenia
61
Q

What is the treatment for scalp dysesthesia?

A

Low dose antidepressant

62
Q

Who is primarily effected by BMS (burning mouth syndrome)

A

post menopausal women

63
Q

What is the treatment for BMS (burning mouth syndrome)

A

topical applications of clonazepam, capsaicin, doxepin, or lidocaine

  • Most commonly used, best studied and most successful is antidepressants
64
Q

What is vulvodynia

A

a vulvar discomfort, usually described as burning pain, occurring without medical findings. Most commonly effecting nulligravid married women in late 30’s.

Chronic if lasting 3 months or longer

Two sub types

  1. localized
  2. generalized
65
Q

What is the treatment for vulvodynia

A

TCA and SSRI and neuroleptics (gabapentin or pregabalin)

66
Q

What is notalgia paresthetica?

A

A unilateral sensory neuropathy characterized by infrascapular pruritus, burning pain, hyperalgesia and tenderness (T2-T6).

A pigmented patch localized to the area of pruritus is often found (secondary to PIH)

67
Q

What is the treatment for notalgia paresthetica

A 
topical capsaicin (relapse in 4 weeks of discontinuation). 
topical lidocaine patch
intradermally with 4U of botox type A spaced 2cm apart
68
Q

What is brachioradial pruritus

A

condition characterized by itching localized to the brachioradial area of the arm.

Cervical spin pathology is frequently found on the radiographic evaluation

69
Q

What is the treatment for brachioradial pruritus

A 
topical capsaicin
Cervical spine manipulation
neck traction
anti-inflammatory medications
PT
70
Q

What is Roth-Bernhardt Disease

A

Meralgia paresthetica

71
Q

What is neuralgia paresthetica?

A

a variety of paresthesia, with persistence numbness and periodic transient episodes of burning or lancinating pain on the anterolateral thigh.

Most offend affected middle age obese men.

May be associated with alopecia localized to the area innervated by the lateral femoral nerve

72
Q

what is CRPS

A

Complex regional Pain Syndrome

burning pain, hyperesthesia and trophic disturbances resulting from injury to a peripheral nerve

The skin of the involved extremity becomes shiny, cold, and atrophic and may profusely perspire

73
Q

What are the 5 features of CRPS

A 
pain
edema
dysregulation of autonomic function
alteration in motor function
dystrophic changes
74
Q

What is trigeminal trophic syndrome

A

interruption of the peripheral or central sensory pathways of the trigeminal nerve may result in a slowly enlarging, unilateral, uninflammed ulcer on ala nasi or adjacent cheek skin.

The nasal tip is spared.

75
Q

What is mal perforans pedis

A

a chronic ulcerative disease seen on the sole in conditions that result in loss of pain sensation at a site of constant trauma.

In most cases mal perforans begins as a circumscribed hyperkeratosis, usually on the ball of the foot.

76
Q

What is the treatment for mal perforans pedis

A

relief of pressure

local and systemic antibiotics

77
Q

What is Morvan’s Disease

A

Syringomyelia

78
Q

What is syringomyelia

A

results from cystic cavities inside the cervical spinal cord, due to alterations of cerebrospinal fluid flow

Disease begins insidiously and gradually causes muscular weakness, hyperhidrosis, and sensory disturbances especially in the thumb, index and middle finger.

79
Q

What is Riley-Day Syndrome

A

Familial dysautonomia

80
Q

What is familial dysautonomia

A

HSAN (III) - Hereditary Sensory and Autonomic Neuropathy

defective lacrimation, decreased pain sensation, impaired temperature and blood pressure regulation and absent tendon reflexes.

Autosomal recessive trait

Andrews Diseases Of Skin (5 decks)

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