Pruritus is defined as an unpleasant sensation that causes a desire to scratch. The terms pruritus and itch are used synonymously. Pruritus is the most common subjective symptom in dermatology and may occur with or without visible skin lesions. It may be localised or generalised.
It is important to distinguish between acute and chronic pruritus. Pruritus lasting >6 weeks is defined as chronic pruritus. Based on aetiology, chronic pruritus may be classified as being of dermatological, systemic, neurological, psychogenic/psychosomatic, mixed, or unknown aetiology. Chronic pruritus can be very distressing and refractory to treatment. Its intensity frequently correlates with degree of quality of life impairment, level of stigmatisation, severity of depression, and emotional stress.
According to the currently accepted clinical classification, patients with pruritus may be characterised as those with itching on primarily diseased, inflamed skin; pruritus on primarily normal, non-inflamed skin; and itchy skin with chronic secondary scratch lesions.
Itching is a common ailment. A large epidemiological study performed in Germany on 11,730 individuals reported a chronic pruritus (at least 6 weeks prior to data collection) point prevalence of 16.8%; prevalence increased with age from 12.3% (16-30 years) to 20.3% (61-70 years). In a self-reported morbidity study conducted in Norway, itch was the most frequently mentioned skin symptom (7%); itch was reported significantly more often by men from East Asia (18%) and the Middle East/North Africa (13%). Patients reporting itch were younger, predominantly female, and more distressed; they had lower income, poorer social support, and experienced more negative life events.
Pruritus is a common symptom of many skin diseases. For example, it is a cardinal symptom of atopic eczema, and all patients with this disease are believed to have pruritus at some point during their illness. Similarly, about 70% to 90% of patients with psoriasis have pruritus. Pruritus may also complicate other systemic diseases, such as chronic renal failure, blood malignancies, or liver disorders. For instance, the frequency of chronic pruritus in haemodialysis patients has been estimated to be between 25% and 55%.
Pathophysiology depends on the underlying disease. Itch may be induced or modulated by many different mediators, including histamine, acetylcholine, catecholamines, haemokinins, chemokines, cytokines (interleukin 2, interleukin 31), neuropeptides, endothelin, endovanilloids, endocannabinoids, hormones of the hypothalamus-pituitary axis, kallikreins, proteases, prostaglandins, leukotriene B4, neurotrophic peptides, and opioids.
A specific neuronal pathway for itch has been identified. Pruritic stimuli are transmitted mainly by mechano-insensitive unmyelinated afferent C-fibres that have a particularly low conduction velocity, large innervation territories, and high transcutaneous electrical threshold.
In the spinal cord, the pruritic stimuli are transferred by specific pruriceptive neurons of dorsal horns to the posterior part of the ventromedial thalamic nucleus, which projects to the dorsal insular cortex. Itch pathway neurons have been identified in the spinal cord showing expression of gastrin-releasing peptide receptors. Induced itch stimuli co-activate the anterior cingulate cortex, supplementary motor area, and inferior parietal lobe predominantly in the left hemisphere.
Following itch induction, the multiple activated sites in the brain argue against the existence of a single itch centre and reflect the multidimensionality of pruritus. Importantly, it has been demonstrated that the brain activity in patients suffering from chronic itch upon pruritic stimuli differs significantly from that observed in healthy subjects.
- Atopic dermatitis
- Insect bite
- Pinworm infection
- Lichen planus
- Skin xerosis
- Cholestatic pruritus
- Chronic renal failure (uraemic pruritus)
- Postherpetic itch
- Drug-induced pruritus
- Post-burn pruritus
- Cutaneous larva migrans
- Tapeworm infection
- Dermatitis herpetiformis
- Bullous pemphigoid
- Iron deficiency anaemia
- Diabetic peripheral neuropathy
- Hodgkin's lymphoma
- Polycythaemia vera
- HIV infection/AIDS
- Thyroid dysfunction
- Paraneoplastic pruritus
- Brachioradial pruritus
- Notalgia paraesthetica
- Brain tumour
- Multiple sclerosis
- Psychogenic pruritus
- Persistent delusional disorders
- Strongyloides infection
Jacek C. Szepietowski, MD, PhD
Head of Department of Dermatology Venereology and Allergology
Wroclaw Medical University
JCS is an author of a number of references cited in this topic. JCS is an investigator for Abbvie, Amgen, Boehringer Ingelheim, Galapagos, InflaRX, Pfizer, UCB, Incyte, Janssen, Helm, Merck, Menlo Therapeutics, Novartis, Regeneron, and Trevi; an advisor for AbbVie, Leo Pharma, Novartis, Pierre-Fabre, Menlo Therapeutics, Sanofi Genzyme, Sienna Biopharmaceuticals, and Trevi; and a speaker for AbbVie, Berlin-Chemie Menarini, Eli Lilly, Janssen, Leo Pharma, Novartis, Sanofi-Genzyme, and SunFarm.
Adam Reich, MD, PhD
Head of Department of Dermatology
University of Rzeszow
AR is an author of a number of references cited in this topic. AR is a consultant or speaker for AbbVie, Bioderma, Celgene, Chema Elektromet, Eli Lilly, Galderma, Janssen, Leo Pharma, Medac, Menlo Therapeutics, Novartis, Pierre-Fabre, Sandoz, and Trevi; and a principal investigator or sub-investigator in clinical trials sponsored by AbbVie, Drug Delivery Solutions Ltd, Galderma, Genentech, Janssen, Kymab Limited, Leo Pharma, Menlo Therapeutics, MetrioPharm, MSD, Novartis, Pfizer, and Trevi.
Sonia Stander, MD, PhD
Professor of Clinical Neurodermatology
Department of Dermatology
SS is an author of a reference cited in this topic.
Uwe Gieler, MD, PhD
Head of Department of Psychosomatic Medicine
UG declares that he has no competing interests.
James De Bloom, MD
South Carolina Skin Cancer Center
JDB declares that he has no competing interests.
- European S2k guideline on chronic pruritus
- British Association of Dermatologists’ guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis
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