Pruritus: Diagnosis and Management

 

Am Fam Physician. 2022 Jan ;105(1):55-64.

  Patient information: See related handout on pruritus, written by the authors of this article.

Author disclosure: No relevant financial relationships.

Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. An exposure history may reveal symptom triggers. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. Primary skin lesions indicate diseased skin, and secondary lesions are reactive and result from skin manipulation, such as scratching. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. Additional testing, including erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography, may also be appropriate based on the history and physical examination. In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. If the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist.

Pruritus is the sensation of itching. Although large-scale epidemiologic data on prevalence are limited, pruritus is a common symptom encountered in primary care.1,2 The etiology of pruritus is complex and can include histamine, serotonin, and neuropeptide release, and neuronal itch signal transmission.1 Risk factors include older age, known or new dermatologic disease, and systemic conditions, such as renal and hepatic disease.1 When inadequately treated, pruritus can adversely affect a patient's quality of life by altering mood, stress levels, and sleep.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Differentiate lesions as primary to pruritus or secondary (e.g., excoriations, scarring). Primary skin lesions indicate skin disease.1,5

C

Expert opinion

Counsel patients with a history of irritant and allergic contact dermatitis to avoid contact irritants and other triggers (e.g., rough textiles, detergents, perfumes, chemicals, dyes).1,4,10

C

Professional society guideline based on expert opinion

The physical examination for pruritus should include a complete dermatologic assessment.1

C

Professional society guideline based on expert opinion

Consider additional skin testing (e.g., biopsy, scraping, culture) for persistent, unexplained pruritus.1,2,10

C

Professional society guideline based on expert opinion

Consider the following serologic studies when pruritus is undifferentiated after initial evaluation: complete blood count, iron studies, renal and hepatic function tests, thyroid-stimulating hormone, and fasting glucose or A1C.1,2,4,10

C

Professional society guidelines based on case-control studies and expert opinion

Encourage liberal use of emollients and limiting water exposure to reduce dry skin.1,47,48

B

Professional society guideline and multiple RCTs for treatment of atopic dermatitis

Use oral antihistamines and topical corticosteroids for initial symptomatic therapy in patients with pruritus.1,37,38,40,41

B

Professional society guideline and several small RCTs

Lifestyle modifications and cognitive behavior therapy can be considered for resistant symptoms of pruritus.1,49

B

Professional society guideline based on a Cochrane review of 10 RCTs


RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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JEDDA RUPERT, MD, FAAFP, is an associate program director of the National Capital Consortium Family Medicine Residency at Fort Belvoir (Va.) Community Hospital, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

JAMES DAVID HONEYCUTT, MD, FAAFP, FAWM, is an associate program director of the Nellis Family Medicine Residency at Mike O'Callaghan Military Medical Center, Nellis Air Force Base, Nev., and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Jedda Rupert, MD, 9300 Dewitt Loop, Fort Belvoir, VA 22060 (email: jedda.rupert@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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