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Pruritus without rash in Adult
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Pruritus without rash in Adult

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Contributors: Susan Burgin MD, Jeffrey D. Bernhard MD, Lowell A. Goldsmith MD, MPH
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Synopsis

Pruritus and itch are synonymous. Itch is defined as a sensation that elicits scratching or the desire to scratch. Many skin diseases, such as psoriasis, atopic dermatitis, and scabies, can be intensely pruritic. In this article we focus not on skin diseases that itch but on itching without a rash – either generalized or localized. In this setting, secondary skin changes such as scratch marks and secondary infection may occur but are not the primary diagnosis. Although there are a number of symptomatic treatments for pruritus, there is no single medication for itch as effective as aspirin is for pain.

Generalized itching without a rash can be an important symptom of internal conditions such as biliary obstruction, renal failure (acute, chronic), hyperthyroidism, Hodgkin disease, other lymphomas, and other myeloproliferative diseases. The connection, if any, between pruritus and solid malignancies is tenuous and exceedingly rare except when, for example, a tumor causes biliary obstruction. Medications can also cause generalized pruritus without a rash.

Diffuse itch with a prickling character that develops immediately after any water contact and lacks associated visible skin changes is called aquagenic pruritus and may be a sign of polycythemia vera. It has also been associated with myelodysplastic syndrome and hypereosinophilic syndrome. Rarely it has been reported as occurring with essential thrombocythemia and myelofibrosis. Some medications have been reported to induce the condition as well.

Localized itching, often with a burning or stinging character, can occur as a consequence of isolated peripheral sensory neuropathies. These abnormal sensations may be described as dysesthetic, paresthetic, or neuropathic. Itch localized to the upper back may represent notalgia paresthetica. Itch localized to the forearms may represent brachioradial pruritus. Dysesthesia of the scalp can occur as a consequence of cervical spine disease. Intense itching of the scalp also occurs in dermatomyositis. On occasion, a localized neuropathic itch such as brachioradial pruritus may trigger generalized pruritus.

Generalized pruritus in the setting of immunocompromise can be a sign of lymphoma, drug reactions, and all of the other conditions associated with generalized itch.

Pruritus of the elderly is probably a consequence of age-related sensory neuropathy, but is ordinarily considered a diagnosis of exclusion.

Related topic: HIV/AIDS-related pruritus

Codes

ICD10CM:
L29.8 – Other pruritus

SNOMEDCT:
276444007 – Generalized pruritus

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

The main systemic causes of generalized pruritus include:
Check for a subtle rash caused by:
The diagnosis of symptomatic dermatographism – a form of physical urticaria – is often missed in patients whose chief complaint is "itching all over without a rash" because it is not thought of, lesions are not present at the time of the exam, it is not recognized, or it is written off as "just a reaction to scratching."

List of drugs commonly associated with generalized pruritus, without primary lesions:
  • Narcotics, etc
  • Opiate agonists, eg, morphine
  • Erythromycin
  • Oral contraceptives
  • Phenothiazines
  • Chlorpropamide
  • Para-aminosalicylic acid
  • Nitrofurantoin
Note: It is said that "any" drug can cause pruritus, but some do so more frequently and others hardly ever. Some of the most important ones are listed in the Drug Reaction Data table. The more common type of drug reaction with itching usually includes an exanthematous rash or hives.

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Updated: 06/15/2018
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Pruritus without rash in Adult
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