Fig. 27.1
Upper panel demonstrates an old woman with long history of generalized pruritus suspected to be psychogenic. Direct immunofluorescence examination confirmed the diagnosis of pemphigoid presenting as generalized pruritus. Lower panel demonstrates a young woman with posttraumatic stress disorders who has generalized pruritus and psychogenic excoriations
Figure 27.1 illustrates two patients with two of the disorders discussed in this chapter.
Case
A middle-aged or elderly person presents with a several month history of generalized pruritus. Examination reveals unremarkable skin or scattered excoriations among otherwise unremarkable skin.
The clinical presentation of generalized pruritus is one of the more challenging clinical presentations in dermatology. It may be due to subclinical or very mild primary dermatologic disorder, and rarely may be the initial presentation of an internal hematologic malignancy or other systemic disorder.
The differential diagnosis includes
Mild or subclinical primary skin disorder such as
xerosis
infestation
dermographism
pemphigoid presenting as generalized pruritus, AND
Systemic disorders such as
hematological disorders and malignancies
endocrine disorders
renal failure
hepatic failure and disorders
psychiatric disorders.
The main responsibility of the dermatologist is to determine which of the two disease groups does the patient’s complaint belong to, hence, which patient requires an extensive and expensive systemic evaluation that may be associated with anxiety by the patient and the family.
Clinical Clues
Generalized Pruritus Secondary to Dermatologic Disorders
The clinical presentation of xerosis is variable. Dry skin may appear ashy especially in dark-skinned individuals without being necessarily rough or obviously scaly. Sweat and/or OTC creams and lotions may also mask the abnormal appearance of the horny layer upon physical examination. Extreme dryness may lead to various clinical presentations of dermatitis, foremost among them are “cumulative insults irritant dermatitis” most often seen on the hands, and “asteatotic dermatitis” or “eczema craquele,” more often seen over the lower legs, more commonly in the elderly.
In some cases in which subclinical dryness may be the cause of generalized pruritus, it is wise to treat the patient for xerosis and reevaluate in few weeks.
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