Pruritus in the Older Patient

Abstract

The Patient's StoryMr A is 85 years old and has multiple skin abnormalities with intractable pruritus of the trunk, groin, perianal area, face, and scalp. He cannot sleep for more than 4 to 5 hours per night because of his pruritus. Mr A was diagnosed as having seborrheic dermatitis, lichen simplex chronicus, seborrheic keratoses, tinea pedis, intertrigo, and xerosis (dry skin) in 2000. Treatments included numerous topical steroids and antifungals. None were effective, leaving Mr A significantly stressed.Mr A lives with his wife in an assisted-living facility. He requires help with dressing, transferring, using the telephone, shopping, and managing medications. His medical history includes type 2 diabetes mellitus, obesity, chronic kidney disease, and significant cardiovascular, cerebrovascular, and peripheral vascular disease. He has had 2 coronary artery bypass graft operations, 2 left carotid endarterectomies, and a left femoral-popliteal bypass operation. He also underwent multilevel lumbar laminectomy for spinal stenosis.His list of 28 oral and inhaled medications includes rosuvastatin and amlodipine. At one visit to Dr I, his geriatrician, Mr A produced 14 different tubes of topical medications, including multiple steroids and antifungals. He and his wife did not understand when and where to apply these medications. Mr A's skin was dry, with erythematous patches, seborrheic keratoses, and areas of excoriation on his trunk. He had bilateral inguinal fold and perianal erythema with a few white perianal plaques and several fissures. On monofilament testing, cutaneous sensation in his feet was absent. Screening for depression was unrevealing. His laboratory test results were notable for mild anemia, elevated creatinine, and normal liver function and routine chemistries.Mr A had several UV-B light treatments, which were minimally helpful. Mr A used over-the-counter diphenhydramine to help him sleep even though Dr I had advised against it because of potential anticholinergic adverse effects. Ultimately, Dr I, in collaboration with IMPORTANCE Pruritus is a common problem among elderly people and, when severe, causes as much discomfort as chronic pain. Little evidence supports pruritus treatment, limiting therapeutic possibilities and resulting in challenging management problems.OBJECTIVES To present the evidence on the etiology, diagnosis, and treatment of pruritus in the elderly and, using the best available evidence, provide an approach for generalist physicians caring for older patients with pruritus.EVIDENCE REVIEW PubMed and EMBASE databases were searched (1946( -August 2013.The Cochrane Database of Systematic Reviews and the Agency for Healthcare Research and Quality Systematic Review Data Repository were also searched from their inception to August 2013. References from retrieved articles were evaluated.FINDINGS More than 50% of elderly patients have xerosis (dry skin). Xerosis treatment should be included in the initial therapy for pruritus in all elderly patients. Calcium channel blockers and hydrochlorot...

Unusual Case of Pruritus Vulvae (Prurigo Nodularis): A Rare Case Report

“…Lesions number from 1-2 to hundreds and may show signs of excoriation with flat, umbilicated, or crusted top. 2,3 In most cases, the disease runs a very protracted course with exacerbations and remissions, as in our case.…”

“…It occurs mainly in adults of both sexes aged 20 to 60years and especially in middle-aged women, although cases affecting children have also been described. 2 Patients with PN invariably complain of a long-standing history of severe, unremitting pruritus. Patients can point out specific areas where they began feeling itchy and where dark-coloured nodules formed soon after.…”

Practice Gaps in Pruritus

“…Medication use should be assessed in patients with generalized pruritus, because calcium channel blockers, hydrochlorothiazide, and other medications may cause itch without any other cutaneous findings. 26 …”

Dermatose oder Symptom einer inneren Erkrankung?

“…nannten paraneoplastischen chronischen Pruritus. Daher ist neben einer genauen Anamnese auch das Abfragen der B-Symptomatik und eine körperliche Untersuchung mit Abtasten der Lymphknoten sinnvoll [11]. Hinter einem lokalisierten Pruritus auf primär unveränderter Haut steht meist eine neurologische Ursache.…”