Understanding Itchy Dermatoses: Pearls and Best Practices

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During a session called "Itchy Dermatoses"¹ at the 2023 Society of Dermatology Physician Assistants (SDPA) Fall Conference in Nashville, TN, presenter Ted Rosen, MD, discussed itching, or pruritus, and the multifaceted role it plays in patient lives.

The session highlighted various aspects of pruritus, from the neurological sensitization of itch to its diverse causes and innovative treatments.

Itch Sensitization and Identifying Etiology

Rosen began the session by discussing the phenomenon of itch sensitization. After so much time spent itching, Rosen said the nerves can become so accustomed to transmitting itch sensations that almost any stimulus can lead to itching, including temperature sensations.

In patients presenting with itching, it is important to consider whether they presented with a visible rash or not, Rosen said. A crucial diagnostic distinction, the presence or absence of a rash, often determines the course of treatment.

Common Causes of Dry Skin

Dry, cracked skin, a common culprit behind pruritus, can result from various factors such as aging, diabetes mellitus, diabetes insipidus, and hypothyroidism.

Conditions such as xerosis cutis, commonly observed in the elderly, were presents as scaly and cracked, and sometimes can be challenging to visualize, Rosen noted. Despite the occurrence of xerosis cutis and certain other conditions most commonly taking place in elderly patients, Rosen said it important that age not act as the sole determinant of a diagnosis. When a condition is said to most commonly occur in elderly patients, it is important not to let statistics deter from recognizing that a young patient may have the condition, too.

In patients with eczema craquele, or dry skin to an extreme, visual presentations may be similar to that of porcelain.

PEARL: When recommending moisturizers for patients with dry skin, ceramide-rich products will most effectively mimic natural skin moisturizer. Ensure, however, that when recommending products, you are specific with the product name.

Scabies, Head Lice, and Body Lice

Rosen also touched upon the challenges posed by scabies, head lice, and body lice. Scabies mites are becoming resistant to traditional treatments like ivermectin and permethrin, necessitating the exploration of alternative options, Rosen noted. He went on to emphasize that elderly adults with a new-onset, widespread itch should be assumed to have scabies incognito.

In the context of head lice, some species have been found to be resistant to traditional treatments, while others may be associated with sensations of stinging or cautions of flammability.

In instances where a patient may present with signs of excoriation without a visible rash, Rosen said it is important to consider whether body lice may be a potential cause. These lice can be found in the seams of clothing.

PEARL: The Nuvo method, which involves saturating the scalp with Cetaphil gentle cleanser and combing out lice, was highlighted as a simple, safe, and cost-effective option with a 98% cure rate when administered consecutively over 3 weeks.

Superficial Fungal Infections

Superficial fungal infections, such as tinea pedia, tinea cruris, and tinea corporis, may be a cause for itch. By collecting samples for a fungal culture or potassium hydroxide preparation test, diagnosis can be made easier, Rosen said.

While topical treatments are considered topline therapeutics for these indications, it important to consider location when prescribing.

"Where you're treating might dictate what topical is better," Rosen said.

Itch in Chronic Skin Conditions

Pruritus is a common complaint in chronic skin conditions like psoriasis and lichen planus. Stress, heat, sweating, and dry skin were identified as common triggers.

PEARL: Rosen noted that aspirin applied topically serves as an excellent option for relieving psoriatic itch in particular.

Closing Thoughts

In closing, Rosen noted that it is important to consider that a cause for itch may not be identifiable in upwards of 30% to 50% of patients with itch.

"You may still not know why they're itching," he said. "The best you can expect is symptomatic relief."

Reference

1. Rosen T. Itchy dermatoses. Presented at: 2023 SDPA Annual Fall Dermatology Conference: October 26-29, 2023; Nashville, TN.

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