Alerts and Notices
SynopsisPruritus is a common problem in patients with human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS). The itch can result from primary HIV-associated rashes, such as pruritic papular eruption and eosinophilic folliculitis, or it can accompany underlying skin conditions such as seborrheic dermatitis, photodermatitis, psoriasis, and atopic dermatitis. Pruritus can also reflect undiagnosed systemic disease or be idiopathic in up to 50% of patients, resulting in severe, chronic, and difficult to control symptoms.
Severe pruritus can occur either in patients who are well-controlled on antiviral therapy or in HIV-infected patients who are not on therapy. Treatment of pruritus should be guided by the primary morphology of the rash or lack thereof. A multiprong approach to treatment may be helpful as underlying dermatoses can be implicated. Idiopathic pruritus should be a diagnosis of exclusion.
Idiopathic, treatment-resistant pruritus is hypothesized to be secondary to the dysregulation of the immune response, which includes hyperactivation of the humoral response in HIV-infected patients. Eosinophilia and/or high IgE levels are sometimes present.
Related topics: pruritus without rash, xerosis
L29.8 – Other pruritus
420721002 – AIDS-associated disorder
Differential Diagnosis & Pitfalls
- Folliculitis – Lesions are always follicular and often concentrated around the trunk; pustules are often present.
- Eosinophilic folliculitis – Lesions favor the scalp, face, and neck.
- Prurigo nodularis – Thickened hyperpigmented nodules, few in number and sparing areas where patients can't scratch, like the mid-back.
- Atopic dermatitis – Dry, scaly, sometimes fissured patches with weeping may be present in those without eczema history.
- Porphyria cutanea tarda – Itchy, painful blisters that heal with scarring are present in sun-exposed areas.
- Contact dermatitis – Nonspecific, eczematous patches, and potential triggering exposures are identified.
- Psoriasis – May be more pruritic in patients with HIV; can be extensive in total body surface area nearing erythroderma.
- Scabies – Burrows in web spaces, intertriginous areas.
- Polycythemia vera – Laboratory abnormalities and itching that is exacerbated by warmth exposure.
- Pruritus secondary to liver disease (see pruritus without rash)
- Pruritus secondary to renal disease (see pruritus without rash)
- Pruritus secondary to xerosis
- Pruritus secondary to thyroid disease
- Medication-induced pruritus
- Pruritus associated with iron deficiency anemia
- Delusions of parasitosis – Diagnosis of exclusion.