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 localized or generalized.
It is important to distinguish between acute and chronic pruritus. Pruritus lasting >6 weeks is defined as chronic pruritus. Based on etiology, chronic pruritus may be classified as being of dermatologic, systemic, neurologic, psychogenic/psychosomatic, mixed, or unknown etiology. Chronic pruritus can be very distressing and refractory to treatment. Its intensity frequently correlates with degree of quality of life impairment, level of stigmatization, severity of depression, and emotional stress.
According to the currently accepted clinical classification, patients with pruritus may be characterized as those with itching on primarily diseased, inflamed skin; pruritus on primarily normal, noninflamed skin; and itchy skin with chronic secondary scratch lesions.
Prevalence increases with age. One systematic review and meta-analysis reported an overall pooled prevalence of pruritus of 21% in older people (ages ≥60 years). One large epidemiologic study conducted in Germany found an increase from 12.3% among young adults (16-30 years) to 20.3% among those aged 61-70 years.
In a self-reported morbidity study conducted in Norway, itch was the most frequently mentioned skin symptom (7%). Patients reporting itch were younger, predominantly female, and more distressed; they had lower income, poorer social support, and experienced more negative life events. Itch was reported significantly more often by men from East Asia (18%) and the Middle East/North Africa (13%).
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 hemodialysis 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, hemokinins, chemokines, cytokines (interleukin 2, interleukin 31), neuropeptides, endothelin, endovanilloids, endocannabinoids, hormones of the hypothalamus-pituitary axis, kallikreins, proteases, prostaglandins, leukotriene B4, neurotropic peptides, and opioids.
A specific neuronal pathway for itch has been identified. Pruritic stimuli are transmitted mainly by mechano-insensitive unmyelinated afferent C-fibers 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 coactivate 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 center 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 (uremic pruritus)
- Postherpetic itch
- Drug-induced pruritus
- Postburn pruritus
- Cutaneous larva migrans
- Tapeworm infection
- Dermatitis herpetiformis
- Bullous pemphigoid
- Iron deficiency anemia
- Diabetic peripheral neuropathy
- Hodgkin lymphoma
- Polycythemia vera
- HIV infection/AIDS
- Thyroid dysfunction
- Paraneoplastic pruritus
- Brachioradial pruritus
- Notalgia paresthetica
- Brain tumor
- Multiple sclerosis
- Psychogenic pruritus
- Persistent delusional disorders
- Strongyloides infection
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