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Grégoire, 54 years old. Diffuse pruritus.
Grégoire, 54 years old. Diffuse pruritus.
Reviewed by Dr. Alexandre, dermatologist.
5 min read
Related topics
- Dryness / Atopy / Eczema
- Grégoire, 54, visits the doctor with diffuse pruritus that has been present for the past 10 months.
- Up to this point, he has not noticed any skin lesions. For that reason, he didn’t visit the doctor earlier, in spite of his discomfort.
- Upon examining him, you notice this type of lesion on all 4 limbs and the back. The lesions have gradually appeared over the last 6 months, along with xerosis lesions.
What do you think are the most important factors to consider when making a diagnosis? (many possible response)
True answer!
Wrong answer!
In the case of pruritus sine materia, a search should be made for:
- Medical history and medications taken.
- Any associated general symptoms (weight loss, asthenia, night sweats).
- Triggering or calming factors and a contagious
- Medical history and medications taken.
- Any associated general symptoms (weight loss, asthenia, night sweats).
- Triggering or calming factors and a contagious
Pruritus sine materia:
- Pruritus sine materia is defined as pruritus with no visible elementary lesions or identified environmental factors.
- There is no evidence of contagiousness among the patient’s close contacts.
- There may be secondary scratching lesions (excoriation, lichenification, impetignization) may be present.
Grégoire tells you that he has a history of hypertension treated with an ARB. He has not noted any cases of pruritus among his close contacts. He tells you that the pruritus gets worse when showering and swimming.
What additional test(s) would you suggest for Grégoire? (many possible response)
True answer!
Wrong answer!
Liver function tests: pruritus can be a warning sign of liver dysfunction, which is why hepatitis blood tests are also carried out and possible drug intoxication is investigated while taking the medical history.
Phosphocalcium blood test: because dyscalcaemia is one of the aetiologies of pruritus sine materia.
Body imaging: because you should always consider searching for lymphoma in cases of chronic pruritus sine materia.
The aetiologies of pruritus sine materia can be (including, but not limited to):
- Drug-induced: opiates, aspirin and NSAIDs, combination birth control pills, certain anti-hypertensive drugs.
- Endocrine and metabolic origin: dysthyroidism, liver disease with or without cholestasis, dyscalcaemia, severe chronic renal failure (particularly in haemodialysis patients).
- Infectious origin: HIV, viral hepatitis.
- Haematological origin: Hodgkin lymphoma, chronic lymphocytic leukaemia, Vaquez disease, essential thrombocythaemia, monoclonal gammopathy.
- Environmental: irritants.
- Psychogenic origin.
Pruritus sine materia requires, in addition to a thorough medical history and clinical examination:
- “Standard” biological work-up with blood count, liver function tests, phosphocalcium test, measurements of electrolytes, creatinine, TSH, and blood sugar.
- Serum protein electrophoresis.
- HIV, HBV, and HCV blood tests.
Imaging or biopsies should be requested as soon as possible if an obvious cause is not found during the initial assessment.
What symptomatic treatment(s) can you suggest for Grégoire between now and the next visit? (many possible response)
True answer!
Wrong answer!
There is no place for oral corticosteroid therapy apart from any aetiological treatment.
Cleansing with a syndet and the application of an emollient are recommended.
H1-antagonists have not been shown to be effective in treating pruritus other than urticaria. You should instead prescribe hydroxyzine, which combines antihistamine, anti-cholinergic, and anxiolytic action and is effective against pruritus and its nocturnal effects (sedative action).
Biological analyses show:
- haemoglobin 19.8 g/dL,
- haematocrit 61%,
- platelets at 495 g/L.
The rest of the assessment was unremarkable. As a reminder, Grégoire has pruritus that gets worse when he goes swimming.
This makes you think of aquagenic pruritus because the symptoms intensify after contact with water. Indeed, aquagenic pruritus corresponds to the onset of pruritus after contact with water, no matter its temperature. It may be associated with skin lesions or be sine materia. The symptoms should also make you suspect Vaquez’s polycythemia, sarcoidosis, Hodgkin lymphoma, haemochromatosis, and mastocytosis. Vaquez disease or polycythaemia is a myeloproliferative neoplasm.
You make a diagnosis of Vaquez disease and refer the patient to a haematologist colleague.
What are the other causes of aquagenic pruritus apart from Vaquez disease? (many possible response)
True answer!
Wrong answer!
All these pathologies can cause aquagenic pruritus.
Annabel Maruani-Raphael
Pediatric dermatologist
,
France
Chronic prutitus has two main causes:
Skin diseases and other diseases (= sine materia).
Pruritus sine materia should be investigated for systemic aetiology.
Cleansing with a syndet and the application of emollients are recommended.
Treatment is based on treating the cause!
Dr
Samuel Sarfati
General practitioner
,
France
Pruritus sine materia should primarily be investigated for a systemic cause through clinical examination, standard biology, phosphocalcium balance, serum protein electrophoresis, and viral serologies.
Use syndet cleansing and apply an emollient.
Preferably, use hydroxyzine as an antihistamine.
Nicolas Dutriaux
Midwife
The midwife, upon encountering such a request from one of her patients, could initiate the biological tests. However, she should refer to the attending physician for an opinion when the pruritus is generalized and not localized to the genital and mammary areas.
Dr
Christelle Besnard-Charvet
Gynaecologist
,
France
In adults, pruritus sine materia should suggest a systemic disease.
It is essential to look for a history of the condition, whether it has been treated with medication, and whether the patient's general condition has been affected.
Initial treatment consists of cleansing with a syndet and application of an emollient.
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