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{{CMG}} [[Ogechukwu Hannah Nnabude, MD]]


==Overview==
==Overview==
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=Historical perspective=
=Historical perspective=
Until recent times, sensations of itch were considered to be largely the same as those of pain. Currently, pruritus is considered to be an autonomous, pain-independent sensation.
Until recent times, sensations of itch were considered to be largely the same as those of pain. Currently, [[pruritus]] is considered to be an autonomous, pain-independent sensation.
Itch, also known as medically pruritus, The first documented definition of itch was given by the German physician Samuel Hafenreffer as an “unpleasant sensation that elicits the desire or reflex to scratch” about 350 years ago. In recent years, pruritus has been determined to be an autonomous, pain-independent sensation.
Itch, also known as medically [[pruritus]], The first documented definition of itch was given by the German physician Samuel Hafenreffer as an “unpleasant sensation that elicits the desire or reflex to scratch” about 350 years ago. In recent years, [[pruritus]] has been determined to be an autonomous, pain-independent sensation.
Pruritus is a frequently misspelled word, often misspelled as "pruritis".
[[pruritus]] is a frequently misspelled word, often misspelled as "pruritis".
Historically, the sensations of itch and pain have not been considered to be independent of each other until recently where it was found that itch has several features in common with pain but exhibits notable differences. Pruritic stimuli mostly create the same reactions as noxious stimuli in experimental animals. As a result, it is difficult to study the physiologic mechanisms of itch in animal models as they lack the ability to discern the differences between both stimuli. Therefore human studies have provided most of the information regarding the processing of pruritic stimuli. It was initially thought histamine was the major chemical involved in mediating pruritus through binding to H1R and activating phospholipase Cβ3 (PLCβ3) and phospholipase A2 (PLA2). Bell et al. demonstrated that histamine promotes the influx of calcium at the axon terminals of the spinal cord neurons via a transient receptor vanilloid 1 (TRPV1) receptor activation and then, through the promotion of a series of intracellular signal activation, eventually lead to the generation of itching sensation. However, the current consensus is that there are other chemical mediators that are highly involved in the promotion of pruritus.
Historically, the sensations of itch and pain have not been considered to be independent of each other until recently where it was found that itch has several features in common with pain but exhibits notable differences. Pruritic stimuli mostly create the same reactions as noxious stimuli in experimental animals. As a result, it is difficult to study the physiologic mechanisms of itch in animal models as they lack the ability to discern the differences between both stimuli. Therefore human studies have provided most of the information regarding the processing of pruritic stimuli. It was initially thought histamine was the major chemical involved in mediating [[pruritus]] through binding to H1R and activating phospholipase Cβ3 (PLCβ3) and [[phospholipase A2]] (PLA2). Bell et al. demonstrated that [[histamine]] promotes the influx of calcium at the axon terminals of the [[spinal cord]] [[neurons]] via a transient receptor vanilloid 1 (TRPV1) receptor activation and then, through the promotion of a series of intracellular signal activation, eventually lead to the generation of itching sensation. However, the current consensus is that there are other chemical mediators that are highly involved in the promotion of [[pruritus]].


=Pathophysiology=
=Pathophysiology=
There are five main causes of itching:
The pathogenesis of itch is characterized by  dermal/pruritoceptive which originates in the skin, neuropathic which is due to damage along the afferent pathway of a nerve, neurogenic itch which originates centrally without the involvement of the peripheral nerves, a [[psychogenic]] itch which is associated with [[psychiatric disorders]] and [[phobias]], and a mixed picture which is due to two or more causes of itching
 
*Dermal/pruritoceptive which originates in the skin,
*Neuropathic which is due to damage along the afferent pathway of a nerve,
*Neurogenic itch which originates centrally without the involvement of the peripheral nerves,
*Psychogenic itch which is associated with psychiatric disorders and phobias, and
*A mixed picture which is due to two or more causes of itching


=Causes=
=Causes=
There are many causes of itching. Examples include skin diseases, systemic diseases, allergies, medications, insect stings among many others
There are many causes of itching. Examples include [[skin diseases]], [[systemic diseases]], [[allergies]], medications, insect stings among many others


=Differentiating Itch from other Disorders=
=Differentiating Itch from other Disorders=
Line 30: Line 24:
About 280 million people globally, roughly 4% of the world's population, have difficulty with itchiness.
About 280 million people globally, roughly 4% of the world's population, have difficulty with itchiness.


Pruritus may be associated with virtually any malignancy. Certain neoplasms, especially hematologic malignancies, have pruritus as a common symptom. For example, in patients with polycythemia vera, 48% to 70% have aquagenic pruritus, which is itching that is associated with water coming in contact with the skin. Also, about 30% of people with Hodgkin's disease suffer from pruritus. The incidence of pruritus in other types of hematologic malignancies is currently not known, however, investigators have reported its presence in approximately 3% of patients with non‐Hodgkin's lymphoma. Solid tumors may be associated with paraneoplastic pruritus. In fact, pruritis may one of the early symptoms, starting months or years before a patient is diagnosed. Pruritus is also a frequent finding in cutaneous lymphomas. Additionally, it is frequently seen in cancers involving the biliary tract. Retrospective studies have revealed that 2% to 11% of chronic itch cases are attributable to malignancies.
[[pruritus]]may be associated with virtually any malignancy. Certain [[neoplasms]], especially [[hematologic malignancies]], have [[pruritus]] as a common symptom. For example, in patients with polycythemia vera, 48% to 70% have aquagenic [[pruritus]], which is itching that is associated with water coming in contact with the skin. Also, about 30% of people with Hodgkin's disease suffer from [[pruritus]]. The incidence of [[pruritus]] in other types of [[hematologic malignancies]] is currently not known, however, investigators have reported its presence in approximately 3% of patients with [[non‐Hodgkin's lymphoma]]. Solid tumors may be associated with [[paraneoplastic]][[pruritus]]. In fact, [[pruritus]] may one of the early symptoms, starting months or years before a patient is diagnosed. [[pruritus]] is also a frequent finding in cutaneous lymphomas. Additionally, it is frequently seen in [[cancers]] involving the [[biliary tract]]. Retrospective studies have revealed that 2% to 11% of chronic itch cases are attributable to [[malignancies]].


Pruritus has been reported to be an early symptom in some non-malignant diseases such as liver disease, renal insufficiency, thyroid disease, Sjögren's syndrome, diabetes mellitus, iron deficiency, paraproteinemia, and other conditions. In internal diseases, itch has been best studied in cholestatic pruritus and uremic pruritus.
[[pruritus]] has been reported to be an early symptom in some non-malignant diseases such as [[liver disease]], [[renal insufficiency]], [[thyroid disease]], [[Sjögren's syndrome]], [[diabetes mellitus]], [[iron deficiency]], [[paraproteinemia]], and other conditions. In internal diseases, itch has been best studied in cholestatic [[pruritus]] and uremic [[pruritus]].


About a third of uremic patients treated without dialysis complain of uremic pruritus, and on maintenance hemodialysis, the incidence of uremic itching rises to 70%-80%.
About a third of uremic patients treated without dialysis complain of uremic [[pruritus]], and on maintenance [[hemodialysis]], the incidence of uremic itching rises to 70%-80%.


Cholestatic pruritis affects nearly if not all patients with biliary cirrhosis and is the first symptom in nearly 50% of the patients with this disease. Furthermore, the prevalence of pruritus in patients with end‐stage HIV is over 20%.
[[Cholestatic pruritus]]]] affects nearly if not all patients with biliary [[cirrhosis]] and is the first symptom in nearly 50% of the patients with this disease. Furthermore, the prevalence of [[pruritus]] in patients with end‐stage [[HIV]] is over 20%.


==Risk Factors==
==Risk Factors==
Common risk factors in the development of [[itch]] are allergic reactions, [[cholestasis]] , [[diabetes mellitus]], and drug side effect.
Common risk factors in the development of [[itch]] are [[allergic reactions]], [[cholestasis]] , [[diabetes mellitus]], and drug side effect.


==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
The scientific term for itching is pruritis. The word pruritis is derived from the Latin word Prurire which means to itch.
The scientific term for itching is [[pruritus]]. The word [[pruritus]]is derived from the Latin word Prurire which means to itch.


In 1660, the German physician Samuel Hafenreffer defined pruritis as "an unpleasant sensation associated with the desire to scratch".
In 1660, the German physician Samuel Hafenreffer defined [[pruritus]] as "an unpleasant sensation associated with the desire to scratch".


In modern medicine, pruritus is used in reference to a pathological condition in which the sensations of itch are intense and often generalized and stimulate repeated scratching in an attempt to alleviate the discomfort. Pruritus is not a disease, but rather a common and still poorly understood symptom of both localized and systemic disorders that may accompany many conditions.
In modern medicine, [[pruritus]] is used in reference to a pathological condition in which the sensations of itch are intense and often generalized and stimulate repeated scratching in an attempt to alleviate the discomfort. [[pruritus]] is not a disease, but rather a common and still poorly understood symptom of both localized and systemic disorders that may accompany many conditions.


Pruritis is important in many medical specialties, and notably to palliative care. Although pruritus is not the most commonly seen symptom seen in advanced terminal disease, it is among the most puzzling symptoms. It can cause considerable discomfort in patients receiving cancer therapy or in other types of terminal diseases. The itch‐scratch‐itch cycle adversely affects skin integrity, resistance to infections, and quality of life as much as pain can affect a patient. It can also lead to feelings of embarrassment which can impact a social patient's life.
[[pruritus]] is important in many medical specialties, and notably to [[palliative care]]. Although [[pruritus]] is not the most commonly seen symptom seen in advanced terminal disease, it is among the most puzzling symptoms. It can cause considerable discomfort in patients receiving [[cancer therapy]] or in other types of terminal diseases. The itch‐scratch‐itch cycle adversely affects skin integrity, resistance to infections, and quality of life as much as pain can affect a patient. It can also lead to feelings of embarrassment which can impact a social patient's life.


==Diagnosis==
==Diagnosis==
Line 54: Line 48:


==Treatment==
==Treatment==
*Medical
===Medical Therapy===
*Primary Prevention
A variety of over-the-counter and prescription anti-itch drugs are available.  Some plant products have been found to be effective [[anti-pruritics]], others not.  Non-chemical remedies include cooling, warming, soft stimulation.
*Secondary Prevention
 
*Cost-Effectiveness of Therapy
Sometimes scratching relieves isolated itches, hence the existence of devices such as the back scratcher.  Often, however, scratching can intensify itching and even cause further damage to the skin, dubbed the "itch-scratch-itch cycle".
*Future or Investigational Therapies
 
The mainstay of therapy for dry skin is maintaining adequate skin moisture and topical [[emollient]]s.
===Primary Prevention===
Effective measures for the primary prevention of [itch] include avoidance of causes, and [[emollient]]s.
===Secondary Prevention===
Effective measures for the secondary prevention of [[itch]] include [[anti-pruritics]], scratching, cooling, warming, soft stimulation.
===Cost-Effectiveness of Therapy===
There has been no discussion on the cost-effectiveness of therapy for[[itch]]
===Future or Investigational Therapies===
There has been no discussion on future or investigational therapies for [[itch]].


==References==
==References==

Latest revision as of 23:52, 13 August 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Ogechukwu Hannah Nnabude, MD

Overview

An itch (Latin: pruritus) is a sensation felt on an area of skin that evokes the desire or reflex to scratch that area. Itching can be related to anything from dry skin to cancer. Itch has many similarities to pain and both are unpleasant sensory experiences but their behavioral response patterns are different. Pain creates a reflex withdrawal while itch leads to a scratch reflex. Unmyelinated nerve fibers for itch and pain both originate in the skin, however, information for them are conveyed centrally in two distinct systems that both use the same peripheral nerve bundle and spinothalamic tract.

Historical perspective

Until recent times, sensations of itch were considered to be largely the same as those of pain. Currently, pruritus is considered to be an autonomous, pain-independent sensation. Itch, also known as medically pruritus, The first documented definition of itch was given by the German physician Samuel Hafenreffer as an “unpleasant sensation that elicits the desire or reflex to scratch” about 350 years ago. In recent years, pruritus has been determined to be an autonomous, pain-independent sensation. pruritus is a frequently misspelled word, often misspelled as "pruritis". Historically, the sensations of itch and pain have not been considered to be independent of each other until recently where it was found that itch has several features in common with pain but exhibits notable differences. Pruritic stimuli mostly create the same reactions as noxious stimuli in experimental animals. As a result, it is difficult to study the physiologic mechanisms of itch in animal models as they lack the ability to discern the differences between both stimuli. Therefore human studies have provided most of the information regarding the processing of pruritic stimuli. It was initially thought histamine was the major chemical involved in mediating pruritus through binding to H1R and activating phospholipase Cβ3 (PLCβ3) and phospholipase A2 (PLA2). Bell et al. demonstrated that histamine promotes the influx of calcium at the axon terminals of the spinal cord neurons via a transient receptor vanilloid 1 (TRPV1) receptor activation and then, through the promotion of a series of intracellular signal activation, eventually lead to the generation of itching sensation. However, the current consensus is that there are other chemical mediators that are highly involved in the promotion of pruritus.

Pathophysiology

The pathogenesis of itch is characterized by dermal/pruritoceptive which originates in the skin, neuropathic which is due to damage along the afferent pathway of a nerve, neurogenic itch which originates centrally without the involvement of the peripheral nerves, a psychogenic itch which is associated with psychiatric disorders and phobias, and a mixed picture which is due to two or more causes of itching

Causes

There are many causes of itching. Examples include skin diseases, systemic diseases, allergies, medications, insect stings among many others

Differentiating Itch from other Disorders

There is a very broad differential diagnosis for itching due to an extensive list of possible causes. Itching may be due to dermatologic disease, systemic disease, reactions to chemicals and medications, weather, or psychiatric disease. Symptoms, laboratory findings, and other diagnostic tests can help narrow down the list.

Epidemiology and Demographics

About 280 million people globally, roughly 4% of the world's population, have difficulty with itchiness.

pruritusmay be associated with virtually any malignancy. Certain neoplasms, especially hematologic malignancies, have pruritus as a common symptom. For example, in patients with polycythemia vera, 48% to 70% have aquagenic pruritus, which is itching that is associated with water coming in contact with the skin. Also, about 30% of people with Hodgkin's disease suffer from pruritus. The incidence of pruritus in other types of hematologic malignancies is currently not known, however, investigators have reported its presence in approximately 3% of patients with non‐Hodgkin's lymphoma. Solid tumors may be associated with paraneoplasticpruritus. In fact, pruritus may one of the early symptoms, starting months or years before a patient is diagnosed. pruritus is also a frequent finding in cutaneous lymphomas. Additionally, it is frequently seen in cancers involving the biliary tract. Retrospective studies have revealed that 2% to 11% of chronic itch cases are attributable to malignancies.

pruritus has been reported to be an early symptom in some non-malignant diseases such as liver disease, renal insufficiency, thyroid disease, Sjögren's syndrome, diabetes mellitus, iron deficiency, paraproteinemia, and other conditions. In internal diseases, itch has been best studied in cholestatic pruritus and uremic pruritus.

About a third of uremic patients treated without dialysis complain of uremic pruritus, and on maintenance hemodialysis, the incidence of uremic itching rises to 70%-80%.

Cholestatic pruritus]] affects nearly if not all patients with biliary cirrhosis and is the first symptom in nearly 50% of the patients with this disease. Furthermore, the prevalence of pruritus in patients with end‐stage HIV is over 20%.

Risk Factors

Common risk factors in the development of itch are allergic reactions, cholestasis , diabetes mellitus, and drug side effect.

Natural History, Complications and Prognosis

The scientific term for itching is pruritus. The word pruritusis derived from the Latin word Prurire which means to itch.

In 1660, the German physician Samuel Hafenreffer defined pruritus as "an unpleasant sensation associated with the desire to scratch".

In modern medicine, pruritus is used in reference to a pathological condition in which the sensations of itch are intense and often generalized and stimulate repeated scratching in an attempt to alleviate the discomfort. pruritus is not a disease, but rather a common and still poorly understood symptom of both localized and systemic disorders that may accompany many conditions.

pruritus is important in many medical specialties, and notably to palliative care. Although pruritus is not the most commonly seen symptom seen in advanced terminal disease, it is among the most puzzling symptoms. It can cause considerable discomfort in patients receiving cancer therapy or in other types of terminal diseases. The itch‐scratch‐itch cycle adversely affects skin integrity, resistance to infections, and quality of life as much as pain can affect a patient. It can also lead to feelings of embarrassment which can impact a social patient's life.

Diagnosis

A proposed approach to the evaluation of itching can be summarized on Itch diagnosis page

Treatment

Medical Therapy

A variety of over-the-counter and prescription anti-itch drugs are available. Some plant products have been found to be effective anti-pruritics, others not. Non-chemical remedies include cooling, warming, soft stimulation.

Sometimes scratching relieves isolated itches, hence the existence of devices such as the back scratcher. Often, however, scratching can intensify itching and even cause further damage to the skin, dubbed the "itch-scratch-itch cycle".

The mainstay of therapy for dry skin is maintaining adequate skin moisture and topical emollients.

Primary Prevention

Effective measures for the primary prevention of [itch] include avoidance of causes, and emollients.

Secondary Prevention

Effective measures for the secondary prevention of itch include anti-pruritics, scratching, cooling, warming, soft stimulation.

Cost-Effectiveness of Therapy

There has been no discussion on the cost-effectiveness of therapy foritch

Future or Investigational Therapies

There has been no discussion on future or investigational therapies for itch.

References

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