![Page 1: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/1.jpg)
Itchy rashes
Maggie Kirkup
SpR Dermatology
Royal United Hospital
Bath
![Page 2: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/2.jpg)
How common is skin disease in the population?
1. Questionnaire - 1217 unselected adultsSkin accounted for 25% of 6009 ailments (Market Research Group 1982)
2. Examination - 55% of population had a skin complaint, 22.5% worthy of medical attention1.
1Rea et al Br J Prev Soc Med 1976; 30: 107-14
![Page 3: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/3.jpg)
Describe itch
• “local discomfort or irritation of the skin, prompting the sufferer to scratch or rub the affected area. It is the main symptom of skin disease”
• “a peculiar tingling or uneasy irritation of the skin that causes a desire to scratch the affected area”
![Page 4: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/4.jpg)
“It feels as though every nerve ending in my body is attacking me intensely at my ankles, feet, lower legs, neck, under the breasts (even the nipples tingle). It's absolutely horrendous! My hands grow red as a beet and the itching nearly takes the skin off my hands as I scratch.”
All Party Parliamentary Report on Impact of Skin Disease. 2003
![Page 5: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/5.jpg)
“ It’s like someone tickling you under the skin”
![Page 6: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/6.jpg)
Pathophysiology
• Debate continues over whether there are specific nerve endings for itch
• Possibly more than one mechanism
![Page 7: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/7.jpg)
Pathophysiology of itch
• Free nerve endings Fibres most concentrated in wrists
and ankles Unmyelinated C fibres to dorsal
horn in spinal cord • Scratching is a spinal reflex
response Ascends to cerebral cortex via spinothalamic tract
• Skin inflammation
• Psychological concerns
• Chemical mediatorsSubstance POpioid and non-opioid peptidesSomatostatinNeurokinin AHistamineSerotoninProstaglandins
• External mediators
Environmental heat or dryness
![Page 8: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/8.jpg)
Approach to diagnosis of itching
• History
including onset, duration, pattern, effect on sleep, previous skin disease, contacts, other medical problems, drugs, response to treatment so far.
• Skin examination
features of rash, post-inflammatory changes, signs of scratching
• General examination
![Page 9: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/9.jpg)
Signs of itching
• distress
• excoriation
• lichenification
• shiny nails
• weals
• nodules
![Page 10: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/10.jpg)
Factors affecting presentation of itchy condition
• age
• self-control/ social setting/ distractions
• other medical conditions/ ability to scratch
• site of itch
• specific skin condition
• duration
![Page 11: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/11.jpg)
Causes of itch
• skin disorders
• systemic disorders
• psychogenic
• habit / itch-scratch cycle
• physiological?
![Page 12: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/12.jpg)
Causes of itch
• skin disorders
• systemic disorders
• psychogenic
• habit / itch-scratch
• physiological?
![Page 13: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/13.jpg)
Common itchy skin disorders in the young
![Page 14: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/14.jpg)
Common itchy skin disorders in the young
• infestations: scabies, lice, threadworms
• eczemas
• urticaria
• psoriasis (sometimes)
• insect bites – papular urticaria
• pityriasis rosea
• viral exanthems
![Page 15: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/15.jpg)
Common itchy skin disorders in the young
• infestations: scabies, lice, threadworms
• eczemas
• urticaria
• psoriasis (sometimes)
• insect bites – papular urticaria
• pityriasis rosea
• viral exanthems
![Page 16: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/16.jpg)
Common itchy skin disorders in the young
• infestations: scabies, lice, threadworms
• eczemas
• urticaria
• psoriasis (sometimes)
• insect bites – papular urticaria
• pityriasis rosea
• viral exanthems
![Page 17: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/17.jpg)
Common itchy skin disorders in the young
• infestations: scabies, lice, threadworms
• eczemas
• urticaria
• psoriasis (sometimes)
• insect bites – papular urticaria
• pityriasis rosea
• viral exanthems
![Page 18: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/18.jpg)
Common itchy skin disorders in the young
• infestations: scabies, lice, threadworms
• eczemas
• urticaria
• psoriasis (sometimes)
• insect bites – papular urticaria
• pityriasis rosea
• viral exanthems
![Page 19: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/19.jpg)
Common itchy skin disorders in the young
• infestations: scabies, lice, threadworms
• eczemas
• urticaria
• psoriasis
• insect bites – papular urticaria
• pityriasis rosea
• viral exanthems
![Page 20: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/20.jpg)
Common itchy skin disorders in the young
• infestations: scabies, lice, threadworms
• eczemas
• urticaria
• psoriasis (sometimes)
• insect bites – papular urticaria
• pityriasis rosea
• viral exanthems
![Page 21: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/21.jpg)
Common itchy skin disorders in mature adults
![Page 22: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/22.jpg)
Common itchy skin disorders in mature adults
• infestations: scabies
• eczemas / nodular prurigo/ xerosis
• urticaria
• psoriasis (sometimes)
• lichen planus
• bullous pemphigoid
• polymorphic light eruption
![Page 23: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/23.jpg)
Common itchy skin disorders in adults
• infestations: scabies
• eczemas / nodular prurigo/ xerosis
• urticaria
• psoriasis (sometimes)
• lichen planus
• bullous pemphigoid
• polymorphic light eruption
![Page 24: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/24.jpg)
Common itchy skin disorders in adults
• infestations: scabies
• eczemas / nodular prurigo/ xerosis
• urticaria
• psoriasis (sometimes)
• lichen planus
• bullous pemphigoid
• polymorphic light eruption
![Page 25: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/25.jpg)
Common itchy skin disorders in adults
• infestations: scabies
• eczemas /nodular prurigo/ xerosis
• urticaria
• psoriasis (sometimes)
• lichen planus
• bullous pemphigoid
• polymorphic light eruption
![Page 26: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/26.jpg)
Common itchy skin disorders in adults
• infestations: scabies
• eczemas/ nodular prurigo/ xerosis
• urticaria
• psoriasis (sometimes)
• lichen planus
• bullous pemphigoid
• polymorphic light eruption
![Page 27: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/27.jpg)
Common itchy skin disorders in adults
• eczemas / nodular prurigo/ xerosis
• urticaria
• psoriasis (sometimes)
• infestations: scabies
• lichen planus
• bullous pemphigoid
• polymorphic light eruption
![Page 28: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/28.jpg)
Less common skin complaints which itch
• dermatitis herpetiformis
• aquagenic pruritus
• T cell lymphomas
• pityriasis rubra pilaris
• onchocerciasis etc etc
![Page 29: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/29.jpg)
Localised itch
• Anogenital/ pruritus ani:
think of threadworms, lichen sclerosis, lice, scabies, contact dermatitis
• Hands:
eczemas, scabies, contact dermatitis
![Page 30: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/30.jpg)
Localised itch
• Anogenital/ pruritus ani:
think of threadworms, lichen sclerosis, lice, contact dermatitis
• Hands:
eczemas, scabies, contact dermatitis
![Page 31: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/31.jpg)
Localised itch
• Flexures: atopic/ seborrhoeic eczema, scabies
• Scalp: lice, seborrhoeic dermatitis, psoriasis
• Any area: discoid eczema, lichen simplex chronicus, contact dermatitis
![Page 32: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/32.jpg)
Less common causes of localised itch
• brachioradial pruritus
• notalgia paraesthetica
![Page 33: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/33.jpg)
Skin disorders which don’t (usually) itch
• psoriasis ?
• acne/ folliculitis
• vasculitis/purpura
• erythema multiforme
• secondary syphilis
![Page 34: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/34.jpg)
Causes of itch
• skin disorders
• systemic disorders
• psychogenic
• habit
• physiological?
![Page 35: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/35.jpg)
Systemic causes of itch
• liver disease
• renal failure
• iron deficiency
• metabolic:
protein, zinc, calcium, vitamin deficiencies
• thyroid disease
![Page 36: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/36.jpg)
Systemic causes of itch (part 2)
• diabetes
• malignancies: lymphoma, PRV,
leukaemias, myeloma
• pregnancy
• neurological
• drugs
![Page 37: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/37.jpg)
Screening investigations in itchy patients with no rash
• Full blood count
• Ferritin
• Renal function
• Liver function
• Thyroid function
• ? Chest X ray
![Page 38: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/38.jpg)
Psychogenic itch
• epidemic forms - hysteria
• delusional parasitosis
• habit - itch/scratch cycle
![Page 39: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/39.jpg)
Management of itching
• Treat the cause
• Treat the itch
![Page 40: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/40.jpg)
Management of itching
• There is no specific drug for itch
![Page 41: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/41.jpg)
Management of itching
• keep looking for a cause
• avoid aggravating factors
temperature, humidity, bedding, clothing
• reduce damage from scratching
clothing, bandaging, cut nails
![Page 42: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/42.jpg)
Management of itching
• topical agents
• gadgets
• systemic agents
• psychological interventions
![Page 43: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/43.jpg)
Topical agents• emollients• antihistamines* - doxepin (Xepin)• unknown mechanism -
crotamiton (Eurax)
calamine• counter-irritant - capsaicin, menthol• local anaesthetics *
• paste bandages *Risk sensitization
![Page 44: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/44.jpg)
Management of itching
• topical agents
• gadgets
• systemic agents
• psychological interventions
![Page 45: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/45.jpg)
Management of itching
• topical agents
• gadgets
• systemic agents
• psychological interventions
![Page 46: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/46.jpg)
Systemic agents
• Opiod antagonists• Ondansetron• Rifampicin• Cholestyramine• Tricyclic antidepressants• Thalidomide• Phototherapy
• Antihistamines ?
![Page 47: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/47.jpg)
Management of itching
• topical agents
• gadgets
• systemic agents
• psychological interventions
![Page 48: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/48.jpg)
Psychological and alternative interventions
• Biofeedback• Behaviour therapy*• Relaxation techniques• Acupuncture• Hypnotherapy• Homeopathy • Self-help groups*Melin I et al Behavioural treatment of scratching in patients with atopic dermatitis.
Brit J Dermatol 1986; 115: 467-74
![Page 49: Itchy rashes Maggie Kirkup SpR Dermatology Royal United Hospital Bath](https://reader036.vdocument.in/reader036/viewer/2022062417/551c36c35503460d398b4734/html5/thumbnails/49.jpg)
Summary
• Itching can be caused by skin disease, systemic disease, psychogenic factors or idiopathic
• Management and investigation need to be tailored to the patient’s condition and circumstances