Pruritic Diseases and Secondary Changes

Question 1

Urticaria most symptomatic

Answer 1

Early lesion and small superficial wheals

Question 2

How to treat urticaria?

Answer 2

Antihistamines - decrease pruritus - leads to resolution of wheals

Question 3

Assessment that should be performed in all patient’s with itch?

Answer 3

Dermatographism (exaggerated wheal development) mark the skin to see if a wheal develops

Question 4

Factors that contribute to itch in atopic dermatitis

Answer 4

Epidermal hyper-innervation and central sensitization

Question 5

What is nemolizumab

Answer 5

anti-IL-31 receptor A medication used to decrease itch

Question 6

Scabies itch starts when

Answer 6

• 3-6 weeks after the initial infection
• within days of subsequent

Question 7

Immune response during scabies targets

Answer 7

Mites

Eggs

Scybala ( fecal matter)

Question 8

CTCL and itch

Answer 8

> 60% of patients have itch

frequency intensifies at later stages i.e Sezary Syndrome

Question 9

What cytokine is associated with itch in CTCL

Answer 9

IL-31

Nemolizumab is an antibody against the IL-31 RA

Question 10

CTCL itch treatment options (experimental)

Answer 10

Nemolizumab

Mogamulizumab

gabapentin 900-2400 mg/day (split into 3 doses)

Mirtazepine 7.5 -15 mg

Naltrexone 50-150 mg/day

Aprepitant (neurokinin 1 blocker)

Question 11

Prurigo Nodularis

Answer 11

Dome shaped, firm, hyperpigmented papulonodules +/- central crust/scale/erosion

Question 12

Prurigo Nodularis Distribution

Answer 12

Symmetrically along the extremities (typically extensor surface)

Butterfly sign with sparing of the upper mid back

Also spares flexural areas, face and groin

Question 13

Prurigo Nodularis Causes

Answer 13

chronic repetitive scratching/picking due to a pruritic systemic or dermatological or psychogenic diseaese

Question 14

Prurigo Nodularis Epidemiology

Answer 14

Middle aged adult with dermatologic/psychiatric diseases

occasionally in children with atopic dermatitis

Question 15

Prurigo Nodularis Pathology

Answer 15

Epidermal hyperplasia

Compact hyperkeratosis

Vertically arranged collagen fibers

increased number of fibroblasts and capillaris

perivascular/ interstitial mixed inflammatory infiltrate

increased dermal nerve fibers

decreased epidermal nerve fibers

Question 16

Prurigo Nodularis Treatments

Answer 16

Psychogenic- SSRIs/TCA

thalidomide (50-200mg/day)/lenalidomide

Liquid nitrogen

Topical capsaicin

calcipotreine

cyclosporine

doxepin

methotrexate

Question 17

Products with anti-itch properties

Answer 17

pramoxine (cerave itch relief)

polidocanol (asclera, vanthena)

palmitoylethanolamine

oral antihistamines

• Non sedating- cetirizine (Zyrtec)

fexofenadine (Allegra)

loratadine (claritin)

desloratadine (clarinex)

Question 18

Lichen simplex chronicus

Answer 18

well defined plaques exhibiting exaggerated skin lines with a leathery appearance

Question 19

Lichen simplex chronicus locations

Answer 19

posteriolateral neck

occipital scalp

anogenital region

shins, ankles

dorsal aspects of the feet,hands forearms

Question 20

lichen simplex chronic pathology

Answer 20

compact hyperkeratosis

acanthosis with irregular elongation

vertically oriented collagen fibers in the papillary dermis

hypergranulosis

Question 21

lichen simplex chronicus epidemiology

Answer 21

more common in older adults

Question 22

lichen simplex chronicus Treatments

Answer 22

Avoidance of scratching/itching

topical / intralesional steriods or calcineurin inhibitors

menthol and pramoxine

anti-histamines

behavioral therapy

lidocaine patch

capsacin patches

Question 23

Scalp pruritus

Answer 23

Primary- lacks skin lesions; associated with anxiety, depression

Secondary- folliculitis, seb derm ,psoriasis

Treatment- emoillents, topical steroid, tar or salicylic acid shampoos, low dose doxepin

Question 24

Pruritus Ani Epidemiology and appearance

Answer 24

Male>> Female- 4:1 ratio

Appear normal to severely irritated

Question 25

Pruritus Ani Causes

Answer 25

Primary: anal pruritus in the absence of a cutaneous, anorectal or colonic disorder

May be due to

Dietary factors

Poor hygiene

Psychogenic

Secondary: due to irritation from stool or hemorrhoids, primary cutaneous disorders, infections/infestations, previous radiation therapy, contact allergy , neoplasms

Question 26

Pruritis Ani Treatment

Answer 26

sitz baths with black tea (astringent)

cool compresses

meticulous hygiene

mild topical steroids/calcineurin inhibitors

treatement of underlying disorders

Question 27

Pruritis Scroti/Vulvae

Answer 27

worse at nigiht

lichenification

Acute causes

infections

allergic dermatitis

irritant dermatiits

Chronic Causes

dermatoses

malignancy

atrophic vulvovaginitis

lumbosacral radiculopathy

irritation

psychogenic (1-7%of cases)

Question 28

Aquagenic pruritis

Answer 28

• severe pruritis or burning pain after water contact

moves from the lower extremities and then generalizes

• Occurs 30 minutes after exposure to water and lasts for up to 2 hours

spares hands, soles and mucosae

• usually secondary to systemic diseaese- Polycythemia vera or skin disorder
• idopathic is relatively uncommon

Question 29

Aquagenic Pruritis Treatment

Answer 29

Alkalinization of baths to pH 8.0

oral antihistamines

phototherapy (UVB, PUVA)

capsaicin cream (3-6 times/day)

clonidine and propranolol for aquadynia

Question 30

Renal Disease pruritis

Answer 30

Localized/generalized intractable, severe paroxysmal pruritis

worse at night and two days after dialysis

Treatments

nb UVB

emoillents

gabapentin

Renal transplant is curative

Question 31

Biliary Pruritis

Answer 31

Causes

obstructive hepatitides

carcinoma