Discussion on Presentation of Patient with generalized itching

1. Case 1,Dermatology Clerkship,
Presented,Prepared by
Cihan Durmuş Saydam, Marmara University School of
Medicine 4’th Year Medical Student,
Student Number: 165114006,
E-mail adress:mdcihansaydam@icloud.com
Date:18’th April 2018

2. Patient History
• 40 years old man has generalized pruritis for one
month. He has weight loss, lethargy, and a mass
on his neck. His physical examination revealed
generalized excoriation, multiple cervical
lymphadenopathies(largest 2*2cm), and
hepatosplenomegaly.
Signs:
• Weight Loss,
• Lethargy,
• Mass on his neck
Physical Examination:
• Generalized Excoriation:Bloody Scratches
• Multiple Cervical Lymphadenopathies(2*2cm at largest)
• Hepatosplenomegaly,

3. Object of Questions
• What do you understand from term «prurigo
generalis»
• What are the changes seen on the skin?
• Which systemic disease may cause generalised
pruritis?
• What may be the cause of itching, if any
underlying disease can not be detected?
• Which laboratory tests are necessary for the
patient who have generalised pruritis?
• How do you treat these patients?

4. • Pruritis: Unpleasent Sensation of the skin to
desire scratching,
• Etiology:
• Primary skin disease accompanying itching,
• underlying systemic disease(renal, hepatic, endocrine, hematologic, neoplastic,
psychiatric),
• drug intake,
• a cutaneous sign or only secondary skin lesions due to scratching(such as
prurigo nodularis, lichen simplex chronicus),
Categorization:
1. Diseased Skin
2. Non-Diseased Skin
3. Chronic Secondary Scratching induced lesions

5. Patient with presenting chief complaint of pruritis
Through History, Complete Skin Examination and Lymph Node Palpation
Identifiable Dermatologic Disease Nonspecific lesion due to scratching
Rubbing, or picking
No identifiable dermatologic disease
• Treat dermatologic disease and
any Associated xerosis or
dermographism
• Symptomatic Treatment of Pruritis,
(such as Anti-histaminics)
Localized or Regional
Unexplained pruritus
Neuropathic Itch and Dysesthesia
Ruled
out
Generalized
Unexplained
Pruritis

6. Generalised Pruritis with Excoriations
Causes
• Renal
• Cholestatic-> Any Liver disease can present with
pruritis: Hepatomegaly
• Hematologic: PCV(Splenomegaly),
• Endocrine
• Malignancy->suspected; Mass in Neck, Multiple
cervical Lymphadenopathies, Splenomegaly,
• Drugs
• Neurologic
• Psychiatric

7. Lymph Node Examination
• Multiple Cervical Lymphadenopathies: may
disclose i.e. lymphoma or another metastases
Paraneoplastic Itch: A systemic reacton to presence of a tumor or
Hematological malignancy, neither induced by local presence of cancer cells
or tumor therapy.
Neoplasm is the underlying reason for Itching Complaint,
Paraneoplastic Itching, most frequently seen with
Myeloproliferative Neoplasm,(e.g. Polycythemia-Vera, Essential Thrombocythemia)
Hodgkin disease
non-Hodgkin lymphomas
Warranting sign is itching unresponsive to conventional therapy,

8. Mechanism of Tumor Associated
Pruritis
• Toxic products from necrotic tumor cells: entering
systemic circulation
• Production of chemical mediators of pruritis by
the tumor,
• Allergic reactions to tumor-specific antigens,
Increased Proteolytic Activity,
Increased Histamine Release
• Obstruction of Biliary tree
• Involvement of tumor in brain

9. Hodgkin Disease
• Classic Presentation: Nocturnal generalized pruritus in
association with chills, sweating, fever
• Persistent pruritis: predictive of a poor prognosis, a «B
Symptom»,
• Eosinophilia and release of histamine(from basophils),
leukopeptidase or bradykinin
• Hepatic involvement by lymphoma(Hepatomegaly finding)
Non-Hodgkin Lymphoma
• Pruritis less prevalently seen in Non-Hodgkin Lymphoma
than in Hodgkin Disease
Leukemia
Chronic Lymphocytic Leukemia(CLL) and Hypereosinophilic
syndromes,
Patients with eosinophilic leukemia and other hematologic
malignancies

10. Questions for Descriptive Features of Pruritus
complaint and Patient History Taking, resp.
• When did it start? Duration: days, months and years
• Where did it start? Where is it now? Localized, generalized, unilateral, bilateral
• How did it start? Onset: Abrupt, gradual, prior history of pruritic syndrome
• How doest it feel? Pricklig, crawling, burning, stinging
• How intense is it? Severity: mild, moderate, severe; interference with Daily activities
• What makes it worse? Provoking/aggravating factors: Heat, Cold, water, air, exercise
• What makes it better? Itch relief: Cold, heat, scratching/rubbing/hurting, cool/hot shower
• What do you think is the cause?
❖ Skin care, bathing habits, personal hygiene, exposure to irritants
❖ Medications
❖ Use of nicotine, alcohol, recreational drugs
❖ Allergies,:drugs, airborne, food, contact
❖ Atopic History, Atopic Dermatitis, Allergic Rhinoconjunctivitis, Asthma
❖ Past and present medical history
❖ Family History: atopy, skin disease,
❖ Sexual history,
❖ Travel History
❖ Dietary habits
❖ Household contacts, personal contacts; pets; Hobies
❖ Prior diagnoses

11. Primary Dermatologic Conditions
Associated with Pruritus
• Inflammation: Atopic Dermatitis, Allergic or
irritant dermatitis, seborrheic dermatitis,
stasis dermatitis, psoriasis, parapsoriasis,
pityriasis rubra, lichen planus, urticaria,
mastocytosis, urticarial dermatitis, drug
eruptions, polymorphous light eruption,
bullous diseases, polymorphic eruption of
pregnancy, eosinophilic folliculitis,
dermatomyositis, prurigo pigmentosa, lichen
sclerosis, graft-versus-host disease,

12. • Infestation/Bites&sting: Scabies, pediculosis, arthropod
bites,
• Infections: Bacterial infections(folliculitis), Viral
infections(varicella), Fungal Infections, Parasitic
infections
• Neoplastic
• Genetic: Hailey-hailey disease, Icthyoses, Sjögren-
Larsson, Porphyrias(Porphyria Cutanea Tarda),
Inflammatory Linear Verrucous Epidermal
Nevus(ILVEN), Large/giant congenital melanocytic nevi
• Other: Xerosis, Eczema-craquelé, Primary cutaneous
amyloidosis, postburn pruritus, scar-associated pruritis,
fiberglas dermatitis,

13. Pruritis in Nonsystemic Disease
Conditions
• Aquagenic Pruritis: usually secondary to systemic
disease(PCV) or another skin
disorder(urticaria,dermographism). Primary form is
relatively rare. Presenting symptoms: prickling, tingling,
burning, or stinging. Typically symptoms begin on the lower
extremities, then generalize with sparing head, mucosa,
palms and soles. Elevated dermal and epidermal levels of
acetylcholine, histamine, serotonin, prostaglandin E2,
• Pruritus in scars; wound healing and resolves over time,
especially in hypertrophic or keloidal scarring. Physical and
chemical stimuli as well as nerve regeneration, Direct
mechanical stimulation; Chemogenic: Histamine,
Vasoactive peptides(kinins), prostaglandins(E1/E2), small
nerve fiber neuropathy

14. • Post-Thermal Burn Pruritus: 85% of patients with
burns experience pruritus during healing phase;
particularly when burns involve the limbs. Deep
dermal burn injury, female gender, psychological
distress
• Fiberglass Dermatitis: Individuals who work in
manufacturing or construction. Severe pruritus
sometimes in the absence of visible skin lesion.
Involvement of hands and other noncovered
sites, such as arms, face, upper trunk; Cutaneous
findings may look like scabies, eczematous
dermatitis,
Pruritis in Nonsystemic Disease
Conditions