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Medical Derm Revision > Pruritus Dan > Flashcards

Pruritus Dan Flashcards

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1
Q

What are the causes of generalized pruritus?

A

AN ITCHING DR
Aquagenic
Neurotic
Idiopathic/ Age-related
Thyroid and other endocrine disease
Cholestasis and Hepatic disease (any cause inc PBC, liver failure or cholestasis)
HIV and infection (GI parasite etc) and Infestations (scabies, thrips, bird mites)
Immunobullous - pre-bullous BP, DH
Neoplasm including hematologic malignancy and anaemia
Gestation (Preg dermatoses etc) and menopause
Drugs esp opiates
Renal

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2
Q

What are the 3 categories ot itch?

A

Pruritus of inflamed/diseased skin
Pruritus of non-diseased/inflamed skin
Itching with secondary lesions due to chronic scratching (includes neurodermatitis)

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3
Q

How may itch be classified based on duration?

A

Acute Chronic >6 wks

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4
Q

T/F

There are separate pathways and receptors for itch and pain

A

True

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5
Q

T/F

stimulation of opioid kappa receptors causes itch

A

False

kappa receptors are anti-itchmu receptors cause itch when stimulated

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6
Q 
T/F
mediators of itch include;
Histamine
Acetylcholine
Substance P
Calcitonin gene related peptide (CGRP)
Opioid peptides
Proteases
Neurotrophins
PgE
Cytokines
A

True

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7
Q

T/F

Formication usually indicates a psychogenic cause for itch

A

True

But consider recurrence due to PNI if this occurs at site of skin cancer excision

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8
Q

T/F

systemic causes of pruritus always cause generalised itch

A

False

Localised itch can still be due to a systemic cause

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9
Q

T/F

Systemic causes of pruritus usually cause chronic progressive generalised itch

A

True

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10
Q

What is the Butterfly sign

A

Sparing of mid upper back where pt can’t reach is called ‘butterfly sign’ is seen in pts whose skin lesions are due to scratching - be wary though as some pts will use scratching device to reach there

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11
Q

How may Hodgkins disease present with pruritus?

A

Generalised nocturnal pruritis
withfever/chillssweatingclassical presentation - dont miss! However the lymphoma may not be identifiable until several years later

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12
Q

T/F

If no cause for pruritus is identified patients should be discharged

A

False
Need to treat itch and follow up as can be sign of a malignancy that will not be evident until laterperiodically screen pts for causes

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13
Q

T/F

Psychogenic pruritus often disturbs sleep

A

False

pruritic skin or other diseases do but psychogenic itch rarely does

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14
Q

Outline your approach to the prutitic patient

A

First exclude pruritic dermatosis, then scabies, scabies, scabies
Do systems review e.g. Diabetes, renal disease, liver disease
Drug Hx e.g. opiates
Check lymph nodes (lymphoma, neoplasm) and full exam - skin, hair, nails and mucous membranes, genitalia
Ix - basic screen Plus additional tests as indicated by above

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15
Q

What are your 1st line pruritus screening testst

A 
FBC, ELFT
TFTs
LDH
ESR
Iron studies - replace if ferritin low
Serum EPP
CXR (neoplasm inc lymphoma)
Beta HCG if female of age
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16
Q

Which types of pruritus respond well to UVB phototherapy?

A 
itch of unknown cause 
renal failure
Polycythaemia rubra vera
Hodgkins
HIV
Aquagenic pruritus
neurodermatitis/ prurigo nodularis
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17
Q

Outline treatments for itch

A

General measures
Keep cool as worse when hot – light, loose clothes, cool shower before bedtime
Take short, lukewarm showers
Avoid soaps
Emollients esp yellow or white soft paraffin
or 5-10% urea cream
Topical antipruritics
Menthol 1-2% in aqueous cream probably best
Calamine used but avoid if xerosis (elderly pruritus etc)
Topical coal tar preparations
Capsaicin may be used for localised itch - TDS
5% doxepin cream has proven anti-itch benefit in eczema (can cause drowsiness)
Corticosteroids for inflammatory skin disease, LSC or prurigo nodules
Systemics
sedating or non-sedating antihistamines
Doxepin 10-25mg nocte
Opioid receptor antagonists – naloxone, naltrexone
SSRIs – paroxetine
SNRI – mirtazepineGabapentin/pregabalin, amitryptaline
Physical
UVB
Trancutaneous nerve stimulation
Acupuncture
Psychological therapies

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18
Q

T/F

Topical local anaesthetics play an important role in the management of pruritus

A

False
short term relief for notalgia paraesthetica but limited role in other causes of itch
Risk of contact sensitization

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19
Q

T/F

Topical antihistamines often help pruritus

A

False

can help for acutely itchy insect bites/stings or for burns but limited role otherwise

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20
Q

T/F

Topical calcineurin inhibitors play limited role in the treatment of itch

A

True
only use for eczema or other itchy dermatosis with proven response to TCNI
Topical 0.03% tacrolimus has evidence in renal pruritus

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21
Q

T/F

Psoriasis is not itchy

A

False

Up to 85% of Pso pts get itchy

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22
Q

T/F

systemic agents are useful for the pruritus of CTCL

A

True
Often itchy esp Sezary or folliculotropic MF
May be helped by topical steroids or phototherapy
If not, systemics are useful esp;naltrexone, gabapentin or mirtazepine

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23
Q

What test is used to look for primary biliary cirrhosis?

A

Anti mitochondrial Abs (AMA)positive in >90% and highly specific

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24
Q

In what condition are anti-smooth muscle Abs found?

A

Autoimmune chronic active hepatitisand in PBC (less often than AMA)

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25
Q

What are the diagnostic criteria for Idiopathic aquagenic pruritis?

A

Severe pruritis after water contact regardless of temp or salinity
Puritus onset within (about 30) minutes without visible skin changes (including dermographism)
Exclusion of other causes inc skin disease, systemic disease and drugs

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26
Q

T/F

Aquagenic pruritus usuallly has an identifiable cause

A

False
cause unknown
diagnosis of exclusion

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27
Q

T/F

Idiopathic aquagenic pruritis resolves after weeks to months

A

False

Chronic and intractable condition

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28
Q

T/F

Idiopathic aquagenic pruritis responds well to antihistamines

A

False

Doesn’t respond to antihistamines

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29
Q

T/F
Idiopathic aquagenic pruritis often starts on lower legs then generalizes but spares palms and soles and head and mucosae

A

True

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30
Q

T/F

Attacks of idiopathic aquagenic pruritus last up to 24 hrs after water exposure

A

False

up to 2 hours

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31
Q

What is the treatment for idiopathic aquagenic pruritus?

A

Full work up exclude other causes
Alkalinize bathwater to pH 8 with baking soda
Capsaicin TDS for 4 weeks may reduce symptoms
nbUVB or PUVA probably best Rx
Cyproheptadine, cimetidine, cholestyramine have been reported to help but only minimally

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32
Q

T/F

A stinging or burning pain after water contact is not consistent with aquagenic pruritus

A

False

can be prickling, tingling stinging or burning

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33
Q

How can the causes of repeated pruritis or paraesthesia on water contact be classified?

A 
With skin findings;
- Mastocytosis
- Hypereosinophilic syndrome
- Haemochromatosis
- Polycythaemia rubra vera PRV
With skin findings when exposed to water only;
- Aquagenic urticaria
- Cold urticaria
- Cholinergic urticaria
Without skin signs;
- Hodgkins disease
- Myelodysplastic syndrome
- Essential thrombocythaemia
- Aquagenic pruritis
- Aquagenic pruritis of the elderly
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34
Q

T/F

keloid scars are ithcy but hypertrophic scars are not

A

False

all scars may be itchy while healing for 6 months to 2 years and both keloid and hypertrophic can remain itchy

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35
Q

T/F

85% of burns pts get itchy when burns healing esp on limbs

A

True

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36
Q

T/F

oral antihistamines help itching scars

A

False
Oral antihistamines not effective
Use emollients, silicone gel and topical or intralesional steroids

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37
Q

T/F

Post burn pruritus is due to histamine release

A 
True
thought to be largely due to histamine
also
nerve trauma/regrowth
opiate analgesia
psychological due to trauma
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38
Q

What factors are predictive of worse post burn pruritus?

A

deep dermal burn
female
high psychological trauma

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39
Q

T/F

Oral gabapentin and topical antihistamines are useful for post burn pruritus

A

True

also massage therapy, oil baths, colloidal oatmeal baths

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40
Q

T/F

Oral pentoxyfylline may reduce the itch of keloids

A

True

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41
Q

T/F

Renal pruritus does not occur in AKI

A

True

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42
Q

T/F

Renal pruritus is due to uraemia

A

False

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43
Q

T/F

Renal pruritus can be localized or generalized

A

True

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44
Q

T/F

Renal pruritus is an independent marker of mortality in CRF

A

True

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45
Q

T/F

Renal pruritus occurs mainly in CAPD pts

A

False

Less often seen in CAPD than haemodialysispts dont need to be on dialysis to get itch

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46
Q

T/F

Itch in haemodialysis pts is least severe the day after dialysis

A

True

Peaks 2 days after last dialysis esp at night

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47
Q

T/F

subtotal parathyroidectomy can improve itch symptoms in some CRF pts

A

True

but not in all of those with elevated PTH

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48
Q

T/F

Renal pruritus occurs only in pts with longstanding CRF of certain aetiologies

A

False

Regardless of aetiology or duration of CRF

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49
Q

What is the main dermatologic differential not to miss in pruritic renal failure pts?

A

reactive perforating collagenosisis associated with CRF

Can also be scabies or any of the other causes and not always renal pruritus

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50
Q

What are the treatments for renal pruritus?

A 
General measures
High-permeability rather than standard dialysis
Topical capsaicin
Topical 0.03% tacrolimus
Activated charcoal 6g PO daily - 1st systemic
Gabapentin/ Pregabalin
Naltrexone
Broad band UVB (can try nbUVB)
Subtotal parathyroidectomy
Renal transplant - curative!
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51
Q

T/F

Cholestatic pruritus is a late feature of liver disease

A

False

can occur early, before other signs

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52
Q

T/F

Cholestatic pruritus often affects the hands and feet

A

True
Generalized and migratory
esp hands, feet and areas under tight clothing

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53
Q

T/F

Cholestatic pruritus is due to the accumulation of bile acids

A

False

this is one theory but bile acids are not always high

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54
Q

T/F

chronic Hep C usually doesnt cause itch as its not cholestatic

A 
False
often itchy
But main causes are cholestatic;
Primary biliary cirrhosis
Primary sclerosing cholangitis
Obstructed bile ducts
Drug induced or other cholestasis inc cholestasis of pregnancy
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55
Q

T/F

Activated charcoal is good for cholestatic pruritus

A

False
Activated charcoal 1st line in renal pruritus but not used in liver
Cholestyramine 4-16g daily 1st line in cholestatic (liver) pruritus - remember CHOLESTyramine for CHOLESTatic pruritus
Cholestyramine can be used for renal pruritus too but not a first choice drug

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56
Q

What are the treatments for cholestatic pruritus?

A 
treat cause of liver failure/cholestasis
General measures
1st line;
Cholestyramine 4-16g daily
Naltrexone/Naloxone 
2nd line;
Ursodeoxycholic acid
Rifampicin
Other systemics and phototherapy are 3rd line
Liver transplant usually curative
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57
Q

T/F

Antihistamines and gabapentin generally not helpful in cholestatic pruritus

A

True

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58
Q

T/F

Iron deficiency can cause generalised or localised pruritus

A

True
inc vulval or perianal
Also can be a sign of Polycthaemia rubra vera, malignancy or other systemic disease which may the true cause of the itch

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59
Q

T/F

In Polycthaemia rubra vera >90% of pts get pruritus

A

False

up to 50%

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60
Q

T/F

In Polycthaemia rubra vera Aquagenic pruritus can precede detectable disease by several years

A

True

be suspicious of this in all pts with aquagenic pruritus

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61
Q

T/F

In Polycthaemia rubra vera, Aquagenic pruritus starts within minutes of getting out of water and lasts up to two hours

A

False

Onset within mins of getting INTO waterLasts 15-60 mins

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62
Q

T/F

UVB or PUVA are first line for the aquagenic pruritus associated with PCV

A

False
First line is to treat the PCV - however itch may persistsponge bath or shower rather than bathaspirin 300mg OD-TDS is first line drugthen can try UVB or PUVA

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63
Q

T/F

Pruritus is a late sign of malignancy

A

False

Cancer may be advanced or pruritus can be very early feature before cancer is detectable

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64
Q

T/F

In Malignancy associated pruritus, degree of itch doesn’t correlate with degree of disease

A

True

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65
Q

T/F

In Hodgkins lymphoma recurrence of pruritus can indicate tumour recurrence

A

True

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66
Q

T/F

Hodgkins lymphoma is strongly associated with pruritus

A

True

Some consider pruritus a B symptom of Hodgkins Dx

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67
Q

T/F

In Hodgkins lymphoma severe, generalized, recalcitrant pruritus predicts poor prognosis

A

True

68
Q

T/F

Topical steroids can be useful in the pruritus of Hodgkins lymphoma

A

True

also mirtazepine

69
Q

T/F

Pruritus in Non-Hodgkins lymphoma is almost as prevalent as in Hodgkins disease

A

False

A lot less - about 10% of cases

70
Q

T/F

CLL is only itchy if the pt has eosinophilic dermatosis of haematologic malignancy

A

False
can be itchy anyway but not commonly
CLL more linked to itch than other leukaemias
CLL also causes eosinophilic dermatosis of haematologic malignancy
hypereosinophilic syndrome is another important leukaemic cause of pruritus

71
Q

T/F

SSRIs and SNRIs are useful in the Rx of malignancy associated itch

A

True
thalidomide also helpful
Remember general emasures and can be multifactorial causes of itch e.g.direct tumour itch+ bile duct obstruction+ chemo drugs+ opiates

72
Q

T/F

Hypothyroidism is more commonly itchy than hyperthyroidism

A

False
Hyperthyroidism more commonly than hypothyroidism
but xerotic skin in hypo can exacerbate itch

73
Q

T/F

Myxoedema of skin is itchy but responds to emollients

A

True

74
Q

T/F

Generalized pruritus is common in diabetes

A

False

rare but can occur

75
Q

T/FDiabetics prone to localised scalp itch resistant to treatment

A

True

76
Q

T/FPoor glycaemic control predisposes diabetic women to local vulval or perianal pruritus

A

TrueCandida may play a role

77
Q

T/FDiabetic neuropathy does not cause itch

A

Falsecan

78
Q

T/F50% of pruritic AIDS pts have another cause of pruritus

A

Truecan be due to AIDS but need to investigate

79
Q

T/FHIV pts may get an itchy exaggerated insect bite response

A

True

80
Q

T/Fsevere itch in HIV pts can indicate high viral load and rapid decline of CD4+ counts

A

Truecan also have high IgE and eosinophilia

81
Q

T/FAntiretroviral therapy for HIV may help itch of HIV but can cause itchy skin eruptions too

A

True

82
Q

T/FTopical steroids and cetirizine are 1st line for the itch of HIV

A

TrueBut need to exclude a cause other than the HIV and ensure HIV treated with HAART

83
Q

T/FGeneralized pruritus is a recognised feature of Bulimia nervosa

A

Falseis a feature of anorexia nervosa

84
Q

T/FPruritus affects 80% of those with CHF or CAD

A

False20-40%

85
Q

T/FItch in CHF affects people’s daily life more than itch in CAD

A

True

86
Q

T/FPeople with CHF have more generalized, more constant itch and longer Hx of itch than those with CAD

A

True

87
Q

T/FItch in CHF is not associated with severity of heart failure

A

FalseThe worse the CHF, the worse the itch

88
Q

T/Fdrugs are thought to be a major cause of itch in CHF pts

A

TrueACEIstatinstransdermally delivered beta blockersloop diureticsallopurinol

89
Q

T/FUp to 80% of pts with prurigo nodules are atopic

A

True

90
Q

What percentage of patients with prurigo nodules have neurodermatitis triggered by insect bites?

A

Triggered by insect bite in up to 20%

91
Q

T/FItch in prurigo nodules is thought to be due to increased substance-P-positive nerves in the hypertrophied skin

A

True

92
Q

T/FPrurigo nodules are usually assymetrical

A

FalseOften symmetrical on extensor surfaces, upper and lower back and buttocks, can be on face or palms

93
Q

What ae the histo features of prurigo nodules?

A

Pseudoepitheliomatous hyperplasiaDense dermal infiltrate with mast cellsCal be eosinophilic depositsCan be increased numbers of Merkel cellsMay see features of chronic eczema or other causative dermatosisCan be neural or vascular hyperplasia

94
Q

What are the DDs of prurigo nodules?

A

perforating disorderspemphigoid nodularishypertrophic LPhypertrophic cutaneous LEscabetic nodulespersistent bite reactionspruriginous dystrophic EBmultiple KAs or granular cell tumours

95
Q

T/FIt is usually unecessary to biopsy prurigo nodules

A

FalseMust biopsy with IMF to confirm diagnosis and exclude DDs including pemphiogid nodularis

96
Q

What is the treatment ladder for prurigo nodules?

A

Need to investigate for causes of pruritus – treat cause if found. Must biopsy with IMFGeneral measures for pruritus and xerosisCut nails short, wear gloves o/nightOcclusion with dressings, bandage or steroid impregnated tapeMenthol creamTopical capsaicin 0.025-0.3% 4-6x per day (Bolognia)Daivonex has been reportedAntihistaminesMay need sedative antihistamine at nightMay need SSRI or doxepinSuper potent TCS under occlusionILCScryotherapynbUVBPUVAExcimer laserSSRIs or doxepin may be helpful esp if compulsive behaviourThalidomide for recalcitrant prurigo nodularisCsA – esp if eczemaAZA has been used

97
Q

T/FPapular eczema/dermatitis is also called chronic prurigo of adults or subacute prurigo and is a type of prurigo nodularis with small papules which is usually a manifestation of eczema

A

TrueBut not always eczemaCan be due to systemic causes of pruritus so need to work up

98
Q

T/FLichen simplex chronicus is most common in young - middle aged women

A

Trueage 30-50 esp

99
Q

T/FCaucasian people have a higher propensity to lichenification of skin from scratching

A

Falsemore in oriental peoples

100
Q

T/FLichen nuchae almost exclusively affects women

A

TrueLSC of neck, behind ears and adjacent scalp

101
Q

T/FThere is an overlaping contium of small pebbly LSC to papular dermatitis esp in atopics

A

True

102
Q

T/FTopical steroids with occlusion are mainstay of treatment for LSC

A

TrueBut not always effective

103
Q

Aside from TCS what other treatments are useful in LSC?

A

Need to explain itch scratch cycle and need to break itConsider need for sedative antihistaminesMay need SSRI or deoxepin if neurotic or depressedAntipruritics - Doxepin cream 5%, capsaicin creamOcclusive dressings/ tar paste medicated bandagesILCS A10 for thick chronic lesionsPsychotherapy

104
Q

T/F20% of pregnant women get some form of pruritus

A

True

105
Q

T/FLocalized anogenital pruritus is most common type of itch in pregnancy

A

Trueoften bacterial or candidal infection present

106
Q

How is scabies treated in pregnancy?

A

6-8% precipitated sulphur in cream or ung base for 3 consecutive days is traditionally 1st lineMany people use topical Benzyl benzoate (Ascabiol lotion=B2)Permethrin is also B2 and many Drs say is okayIvermectin is B3 and MIMs states should not be used in pregnancy

107
Q

T/FOld age pruritus is a diagnosis of exclusion

A

Truebut the drier the skin the more likely this is going to be correct

108
Q

T/FOld age pruritus starts in those over 80

A

Falsecan be anyone over 60can start earlier in women as can be a continuation of perimenopausal pruritus

109
Q

T/FOld age pruritus affects over 50% of those over 60

A

True

110
Q

T/FOld age pruritus is largely due to dry skin

A

TrueNeed frrequent application of greasy emollientsavoid TCS, calamine and antihistaminesconsider adjusting humidity of home/ nursing home

111
Q

T/FAquagenic pruritus of the elderly is usually due to a malignancy

A

Falsedue to very dry skin esp in overheated nurisng homesUnusual in Qld

112
Q

T/FPruritus is a side effect of specific drugs

A

FalseAny drug can cause pruritussome are more likely than others

113
Q

T/FDrug induced pruritus is usually as part of a visible drug eruption

A

TrueBut can be various other mechanisms or may be unknown

114
Q

T/Fsebostasis and resultant pruritic xerosis is caused byRetinoids, beta blockers, tamoxifen and clofibrate

A

True

115
Q

T/FMethamphetamines, opiates and cocaine cause pruritus by neurological mechanisms

A

True

116
Q

T/FChloroquine, clonidine, gold salts and lithium cause pruritus by cholestasis

A

Falsemechanism unknown for this groupCholestasis caused by;Chlorpromazine, Oestrogens, Sulfonamides, Eryhtromycin estolate, Captopril

117
Q

T/FTopicals rarely effective for psychogenic pruritus

A

True

118
Q

T/FPsychogenic pruritus includes anxiety/ neurotic excoriations, neurodermatitis, delusions of parasitosis and related conditions or frank psychosis

A

Trueimportant to rule out an organic cause

119
Q

T/FPruritus caused by nerve problems is a type of dysaesthesia

A

True

120
Q

T/FNeuropathic pruritus is itch caused by a peripheral nerve pathology

A

True

121
Q

T/FNeurogenic pruritus is itch caused by a peripheral nerve pathology

A

Falsethis is neuropathic pruritusNeurogenic is when it is caused by CNS pathology

122
Q

T/FBrachioradial pruritus (BRP) is a type of neuropathic dysaethesia

A

Truealong with itch due to;Notalgia paraestheticaCheiralgia paraestheticaMeralgia paraestheticaTrigemminal trophic syndrome

123
Q

T/FBrachioradial pruritus (BRP) is almost always bilateral

A

FalseCan be bi or uni lateral

124
Q

T/FBrachioradial pruritus (BRP) usually involves the shoulder, chest, neck and upper back

A

FalseUsually localised to dorsolateral forearm(s) and elbow(s) but can involve more proximal areas

125
Q

T/Fhyperaesthesia to pin prick in the distribution of a cervical nerve can be a finding in BRP

A

True

126
Q

T/Fboth cumulative solar damage and cervical nerve root impingement seem to be important aetiological factors in BRP

A

True

127
Q

T/FThe nerves most often affected in Brachioradial pruritus (BRP) are T1-T4

A

FalseCervical spinal nerves C5-C8(brachial plexus is C5-T1)

128
Q

T/FThe skin over the belly of the brachioradialis muscle is the most common site for excorations etc in BRP

A

True

129
Q

T/FA neurological examination of the upper limb is mandatory in suspected BRP

A

Trueexamine skinGALS exam for shoulder and spine deformityAssess sensory and motor function of upper limb(s)

130
Q

T/FMRI of C-spine in suspected BRP may show causes of nerve impingement including;cervical ribdegenerative spine arthropathyspinal tumours

A

True

131
Q

T/FBilateral BRP should raise the suspicion of a spinal tumour or SOL

A

True

132
Q

T/FIn BRP scratching often makes it worse rather than relieving

A

TruePts often use ice packs for cooling

133
Q

T/FBRP usually doesn’t respond to TCS or antihistamines

A

TrueSun protection importantTopical capsaicinGabapentinPhysioDeep intramuscular stimulation acupuncture to the paravertebral muscles in the affected dermatomes

134
Q

T/FCutaneous dysaesthesia means chronic skin symptoms without any objective findings

A

TrueIn these conditions it can be hard for the pt to distinguish between itch and pain and may have both

135
Q

T/FNotalgia paraesthetica is a local intense pruritus of upper back esp medial border/inferior tip of scapula

A

True

136
Q

T/FSymptoms of notalgia paraesthetica may include;painitchparaesthesiahyperaesthesiahyperalgesiahypoaesthesia

A

Truethese areparaesthesia (tingling or pins and needles)hyperaesthesia (increased sensitivity to stimuli including pain)hyperalgesia (increased pain response)hypoaesthesia (reduced sensitivity to stimuli)

137
Q

T/FThe region of skin affected by notalgia paraesthetica corresponds to the innervation of C5-C8

A

FalseT2-T6(posterior rami)

138
Q

T/FSkin consequences of notalgia paraesthetica includehyperpigmenattionLSCMacular amyloidosis

A

True

139
Q

T/FThe symptoms of notalgia paraesthetica always stay localised to the shoulder tip area

A

FalseSometimes symptoms become more widespread and can include scalp

140
Q

T/FIn notalgia paraesthetica, >95% have a spinal pathology affecting the posterior rami in the associated dermatomes (T2-6) causing impingement of the nerve(s) as they pass through the muscles

A

Falseabout 60%

141
Q

T/FIncreased prevalence of notalgia paraesthetica in pts with MEN2A

A

True

142
Q

What are the treatments for notalgia paraesthetica?

A

Consider T spine imaging – X-ray or MRI – high rate of pathology found but often little can be done1st line;Reducing dose of topical capsaicin (0.025% - 0.075%) may help symptoms – start 5x per day and reduce over 4 weeksLignocaine patch 5% (Versatis in Aus)2nd line;Topical anaesthetics – EMLAGabapentinOxcarbazepine 300-600mg BD (antiepileptic)TENS or cutaneous field stimulation3rd line;AcupunctureBoTox AVertebral nerve block with bupivacaine + methylpredSpinal physio w/ Ultrasound and manipulation

143
Q

What is the general Rx ladder for neuropathic dysaethesias?

A 
Capsaicin
Gabapentin
Physio
nerve stimulation
nerve blocks
acupuncture
surgery if amenable problem found on imaging
topical LA good for notalgia paraesthetica
144
Q

T/FAllodynia is often a feature of notalgia paraesthetica

A

False
allodynia often in meralgia paraesthetica(= pain sensation from non painful stimulus)In NP there ishyperaesthesia (increased sensitivity to stimuli including pain)hyperalgesia (increased pain response)

145
Q

What is the cause of meralgia paraesthetica?

A

Usually due to pressure on lateral femoral cutaneous nerve as it passes under inguinal ligament
Rarely due to an L1-4 radiculopathy

146
Q

What are the risk factors for Meralgia paraesthetica?

A 
obesity
pregnancy
prolonged sitting
tight clothing
carrying heavy wallet in trouser pocket
147
Q

T/FMeralgia paraesthetica doesnt have a patch of hyperpigmentation like notalgia paraesthetica

A

False

May or may not be patch

148
Q

What are the treatments of Meralgia paraesthetica?

A

Relieve pressure by addressing risk factorsNerve blockSurgical decompressionOther list of Rxs for neuropathic dysaethesias

149
Q

What is Cheiralgia paraesthetica?

A

Entrapment of radial nerveCauses symptoms on dorsal 1st webspace region of hand

150
Q

Where is the nerve lesion in Trigeminal trophic syndrome?

A

sensory portion of the maxillary branch of the trigeminal nerveresulting in paraesthesia and dysaesthesia of a region of skin centred on the nasal ala

151
Q

Why is the tip of the nose spared in Trigeminal trophic syndrome?

A

It is supplied by the external nasal branch of the anterior ethmoidal nerve arising from the ophthalmic branch of the trigeminal nrve

152
Q

T/FThe ulcer caused by picking in Trigeminal trophic syndrome may extend onto cheek and upper lip

A

True

153
Q

What are the causes of nerve damage resulting in Trigeminal trophic syndrome?

A

iatrogenic ablation of the Gasserian ganglion when treating trigeminal neuralgia by surgery or alcohol injections
infection (VZV, HSV, mycobacteria/ leprous neuritis)
occlusive CVA (posterior inferior cerebellar artery)
syringobulbiaCNS tumour (esp posterior fossa) or treatment of a CNS tumour
post-encephalitic Parkinsonism
brainstem infarcts

154
Q

T/FTrigeminal trophic syndrome can be centred on the lateral forehead, scalp or cheeks

A

Truerarely

155
Q

T/FIn Trigeminal trophic syndrome the ipsilateral corneal reflex may be absent

A

True

should send to ophthal if suspected

156
Q

T/Fhypoaesthesia is seen in Trigeminal trophic syndrome

A

Truereduced sensation to pain (hypoalgesia) and touch in general (hypoaesthesia)

157
Q

What are the DDs for Trigeminal trophic syndrome?

A

BCC, also SCCnasal NK/T cell lymphomaInfections: HSV, Leishmani spp., dimorphic fungi, yawsInflammatory: vasculitis e.g. Wegener’s granulomatosis, pyoderma gangrenosumDermatitis artefacta

158
Q

What are the treatments for Trigeminal trophic syndrome?

A

Multidisciplinary Rx - Pt, carer/family, GP, Derm, Ophthal, Neurology, Plastics, OT, wound care nurse
Pt education very important. Difficult in confused pts, wearing gloves may help
Dressings can help protect the area and promote healing
Wear a protective barrier at night
Inhibit sensations with carbamazepine, diazepam, amitryptaline, chlorpromazine
Cervical sympathectomy, transcutaneous electrical stimulation
Surgical repair of defect with an innervated skin flap offers good chance of recovery

159
Q

What is Trigeminal neuralgia?

A

Recurrent paroxysms of sharp pain in a territory of one of the sensory divisions on CNV
Old name is Tic douloureux

160
Q

What is Levator ani syndrome?

A

Brief burning pain in rectal or perineal area or tenesmus
Triggered by elimination or sitting down
Unknown aetiology
Also called proctodynia, piriformis syndromeProctalgia fugax is a variant

161
Q

What is Proctalgia fugax?

A

Variant of levator ani syndrome
Mainly young adult males
Often occurs at night – may wake pt from sleep
Sudden onset cramp-like or stabbing pain in rectal area which resolves in few minutes or is relieved by digital dilatation of anal sphincter

162
Q

What is Coccydynia?

A

Intermittent or persistent burning pain localised to coccyx

163
Q

What is Male genital pain syndrome?

A

Continuous, intermittent or episodic pain during micturition, exercise, penetration or ejaculation

164
Q

What is Episodic burning perineal pain with itch?

A 
Type of Dysaesthetic anogenital pain syndrome
Symptoms as per the name
Stressed individuals
Short lived intense symptoms
May be precipitated by full rectum
Skin is normal
?type of dermatological ‘non-disease’
165
Q

What is Koro?

A

Psychogenic disorder mainly in japanAcute anxiety and fear related to sensation of genitalia being inwardly retractedMay be burning pain

166
Q

T/F

Patients with pruritus of unknow cause are at increased risk of haematological malignancy and cholangiocarcinoma only

A

True

ensure age appropriate screen UTD and look for features of these in particular but no need for tumour markers etc

167
Q

What is aprepitant? what kind of itch is it good for?

A 
neurokinin-1 receptor inhibitor
is available in Aus – used for N&V in chemo
Good for itch from
atopic dermatitis
prurigo nodules
EGFR inhibitors

Medical Derm Revision (51 decks)

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