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Pruritus and Systemic Disease Workup

  • Author: David F Butler, MD; Chief Editor: William D James, MD  more...
 
Updated: Mar 08, 2016
 

Laboratory Studies

When a primary dermatologic condition is excluded and a systemic cause is suspected, certain laboratory tests may aid diagnosis. If suspicion is low concerning a systemic disease, a 2-week trial of therapy with oilated soap for bathing, emollients for after the bath, and oral antihistamines may be attempted. If this fails, a laboratory evaluation is indicated.

The following screening laboratory tests are recommended:

  • CBC count with differential: This test assists in uncovering polycythemia vera, in which the hemoglobin level, hematocrit value, WBC count (including absolute neutrophil count; see the Absolute Neutrophil Count calculator), and platelet count are elevated. Abnormalities are also seen in persons with hematologic malignancies. Patients with iron deficiency may have microcytosis and low hemoglobin levels. However, those with pruritus and iron deficiency may not be anemic; tests of and serum iron, ferritin, and total iron-binding capacity may be ordered to confirm or exclude the diagnosis.
  • Serum creatinine and blood urea nitrogen values: Persons with CRF have elevated levels.
  • Serum alkaline phosphatase and bilirubin, direct and indirect: Elevated levels may suggest cholestasis. If elevated, antimitochondrial antibody and serum anti–hepatitis C tests may be ordered to confirm primary biliary cirrhosis and hepatitis C, respectively, if these are suspected. Other tests may be needed to confirm other causes of cholestasis. A positive antimitochondrial antibody finding has 98% specificity for primary biliary cirrhosis.
  • Thyrotropin and thyroxine: The results assist in ruling out hypothyroidism and hyperthyroidism.
  • Fasting glucose value, if prompted by signs or symptoms
  • Stool for occult blood in patients aged 40 years or older: A positive result suggests possible malignancy in the GI tract.
  • HIV antibody test, if risk factors are present
  • Skin biopsy for routine pathology and immunofluorescence to exclude subacute occult autoimmune conditions such as pemphigoid and dermatitis herpetiformis
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Imaging Studies

In patients with Hodgkin disease, chest radiography may help in detecting lymphadenopathy in the mediastinum. If cholestasis is present, abdominal ultrasonography may be performed to evaluate the biliary tract.

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Other Tests

When the results of initial laboratory screening are negative and when the physician still suspects a systemic cause, tests of the following may be ordered:

  • Serum protein electrophoresis
  • Stool for ova and parasites
  • Stool for occult blood (may reveal source for anemia)
  • Urine for hydroxy indole acetic acid (5-HIAA) and mast cell metabolites

Negative findings from the initial evaluation do not necessarily exclude systemic disease, and follow-up screening may be repeated every 3-6 months if clinical suspicion continues.

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Procedures

Endoscopic retrograde cholangiopancreatography should be performed when primary sclerosing cholangitis, choledocholithiasis, or obstructive malignancy is suspected.

Skin biopsy for direct immunofluorescence and special stains may help exclude a primary dermatologic condition, such as dermatitis herpetiformis or bullous pemphigoid (ie, pruritic pemphigoid), or confirm a systemic cause, such as in mastocytosis.

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Histologic Findings

Because skin lesions are most likely secondary to scratching, biopsy reveals nonspecific findings. Histologic features may include a hyperkeratotic epidermis with acanthosis and parakeratosis and elongation of the rete ridges. A perivascular lymphoid infiltrate may be present.

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Contributor Information and Disclosures
Author

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Society for Investigative Dermatology, Association of Professors of Dermatology, North American Hair Research Society

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Franklin Flowers, MD Department of Dermatology, Professor Emeritus Affiliate Associate Professor of Pathology, University of Florida College of Medicine

Franklin Flowers, MD is a member of the following medical societies: American College of Mohs Surgery

Disclosure: Nothing to disclose.

References
  1. Cho YL, Liu HN, Huang TP, Tarng DC. Uremic pruritus: roles of parathyroid hormone and substance P. J Am Acad Dermatol. 1997 Apr. 36(4):538-43. [Medline].

  2. Tarikci N, Kocatürk E, Güngör Ş, Topal IO, Can PÜ, Singer R. Pruritus in Systemic Diseases: A Review of Etiological Factors and New Treatment Modalities. ScientificWorldJournal. 2015. 2015:803752. [Medline].

  3. Cowden JM, Zhang M, Dunford PJ, Thurmond RL. The histamine H4 receptor mediates inflammation and pruritus in Th2-dependent dermal inflammation. J Invest Dermatol. 2010 Apr. 130(4):1023-33. [Medline].

  4. Chou FF, Ho JC, Huang SC, Sheen-Chen SM. A study on pruritus after parathyroidectomy for secondary hyperparathyroidism. J Am Coll Surg. 2000 Jan. 190(1):65-70. [Medline].

  5. Hampers CL, Katz AI, Wilson RE, Merrill JP. Disappearance of "uremic" itching after subtotal parathyroidectomy. N Engl J Med. 1968 Sep 26. 279(13):695-7. [Medline].

  6. Massry SG, Popovtzer MM, Coburn JW, Makoff DL, Maxwell MH, Kleeman CR. Intractable pruritus as a manifestation of secondary hyperparathyroidism in uremia. Disappearance of itching after subtotal parathyroidectomy. N Engl J Med. 1968 Sep 26. 279(13):697-700. [Medline].

  7. Graf H, Kovarik J, Stummvoll HK, Wolf A. Disappearance of uraemic pruritus after lowering dialysate magnesium concentration. Br Med J. 1979 Dec 8. 2(6203):1478-9. [Medline].

  8. Kyriazis J, Glotsos J. Dialysate calcium concentration of</=1.25>Nephron</i>. 2000 Jan. 84(1):85-6. [Medline].

  9. Zucker I, Yosipovitch G, David M, Gafter U, Boner G. Prevalence and characterization of uremic pruritus in patients undergoing hemodialysis: uremic pruritus is still a major problem for patients with end-stage renal disease. J Am Acad Dermatol. 2003 Nov. 49(5):842-6. [Medline].

  10. Kumagai H, Ebata T, Takamori K, Muramatsu T, Nakamoto H, Suzuki H. Effect of a novel kappa-receptor agonist, nalfurafine hydrochloride, on severe itch in 337 haemodialysis patients: a Phase III, randomized, double-blind, placebo-controlled study. Nephrol Dial Transplant. 2010 Apr. 25(4):1251-7. [Medline].

  11. Phan NQ, Bernhard JD, Luger TA, Ständer S. Antipruritic treatment with systemic μ-opioid receptor antagonists: a review. J Am Acad Dermatol. 2010 Oct. 63 (4):680-8. [Medline].

  12. Kremer AE, Martens JJ, Kulik W, Ruëff F, Kuiper EM, van Buuren HR, et al. Lysophosphatidic acid is a potential mediator of cholestatic pruritus. Gastroenterology. 2010 Sep. 139 (3):1008-18, 1018.e1. [Medline].

  13. Diehn F, Tefferi A. Pruritus in polycythaemia vera: prevalence, laboratory correlates and management. Br J Haematol. 2001 Dec. 115 (3):619-21. [Medline].

  14. Fett N, Haynes K, Propert KJ, Margolis DJ. Five-year malignancy incidence in patients with chronic pruritus: a population-based cohort study aimed at limiting unnecessary screening practices. J Am Acad Dermatol. 2014 Apr. 70 (4):651-8. [Medline].

  15. Rowe B, Yosipovitch G. Malignancy-associated pruritus. Eur J Pain. 2016 Jan. 20 (1):19-23. [Medline].

  16. Hundley JL, Yosipovitch G. Mirtazapine for reducing nocturnal itch in patients with chronic pruritus: a pilot study. J Am Acad Dermatol. 2004 Jun. 50(6):889-91. [Medline].

  17. Demierre MF, Taverna J. Mirtazapine and gabapentin for reducing pruritus in cutaneous T-cell lymphoma. J Am Acad Dermatol. 2006 Sep. 55(3):543-4. [Medline].

  18. Anand S. Gabapentin for Pruritus in Palliative Care. Am J Hosp Palliat Care. 2012 May 2. [Medline].

  19. Stander S, Siepmann D, Herrgott I, Sunderkotter C, Luger TA. Targeting the neurokinin receptor 1 with aprepitant: a novel antipruritic strategy. PLoS One. 2010 Jun 4. 5(6):e10968. [Medline]. [Full Text].

  20. Yosipovitch G, Maibach HI, Rowbotham MC. Effect of EMLA pre-treatment on capsaicin-induced burning and hyperalgesia. Acta Derm Venereol. 1999 Mar. 79(2):118-21. [Medline].

  21. Kuypers DR, Claes K, Evenepoel P, Maes B, Vanrenterghem Y. A prospective proof of concept study of the efficacy of tacrolimus ointment on uraemic pruritus (UP) in patients on chronic dialysis therapy. Nephrol Dial Transplant. 2004 Jul. 19(7):1895-901. [Medline].

  22. Chen YC, Chiu WT, Wu MS. Therapeutic effect of topical gamma-linolenic acid on refractory uremic pruritus. Am J Kidney Dis. 2006 Jul. 48(1):69-76. [Medline].

  23. Boardman LA, Cooper AS, Blais LR, Raker CA. Topical gabapentin in the treatment of localized and generalized vulvodynia. Obstet Gynecol. 2008 Sep. 112(3):579-85. [Medline].

  24. Blachley JD, Blankenship DM, Menter A, Parker TF 3rd, Knochel JP. Uremic pruritus: skin divalent ion content and response to ultraviolet phototherapy. Am J Kidney Dis. 1985 May. 5(5):237-41. [Medline].

  25. Gilchrest BA, Rowe JW, Brown RS, Steinman TI, Arndt KA. Ultraviolet phototherapy of uremic pruritus. Long-term results and possible mechanism of action. Ann Intern Med. 1979 Jul. 91(1):17-21. [Medline].

  26. Giovannetti S, Barsotti G, Cupisti A, et al. Oral activated charcoal in patients with uremic pruritus. Nephron. 1995. 70(2):193-6. [Medline].

  27. Hiroshige K, Kabashima N, Takasugi M, Kuroiwa A. Optimal dialysis improves uremic pruritus. Am J Kidney Dis. 1995 Mar. 25(3):413-9. [Medline].

  28. Pederson JA, Matter BJ, Czerwinski AW, Llach F. Relief of idiopathic generalized pruritus in dialysis patients treated with activated oral charcoal. Ann Intern Med. 1980 Sep. 93(3):446-8. [Medline].

  29. Jedras M, Zakrzewska-Pniewska B, Wardyn K, Switalski M. [Uremic neuropathy--II. Is pruritus in dialyzed patients related to neuropathy?]. Pol Arch Med Wewn. 1998 Jun. 99(6):462-9. [Medline].

  30. Silva SR, Viana PC, Lugon NV, Hoette M, Ruzany F, Lugon JR. Thalidomide for the treatment of uremic pruritus: a crossover randomized double-blind trial. Nephron. 1994. 67(3):270-3. [Medline].

  31. Legroux-Crespel E, Cledes J, Misery L. A comparative study on the effects of naltrexone and loratadine on uremic pruritus. Dermatology. 2004. 208(4):326-30. [Medline].

  32. Pauli-Magnus C, Mikus G, Alscher DM, et al. Naltrexone does not relieve uremic pruritus: results of a randomized, double-blind, placebo-controlled crossover study. J Am Soc Nephrol. 2000 Mar. 11(3):514-9. [Medline].

  33. Balaskas EV, Uldall RP. Erythropoietin treatment does not improve uremic pruritus. Perit Dial Int. 1992. 12(3):330-1. [Medline].

  34. De Marchi S, Cecchin E, Villalta D, Sepiacci G, Santini G, Bartoli E. Relief of pruritus and decreases in plasma histamine concentrations during erythropoietin therapy in patients with uremia. N Engl J Med. 1992 Apr 9. 326(15):969-74. [Medline].

  35. Manenti L, Vaglio A, Costantino E, et al. Gabapentin in the treatment of uremic itch: an index case and a pilot evaluation. J Nephrol. 2005 Jan-Feb. 18(1):86-91. [Medline].

  36. Dawn AG, Yosipovitch G. Butorphanol for treatment of intractable pruritus. J Am Acad Dermatol. 2006 Mar. 54(3):527-31. [Medline].

  37. Najafabadi MM, Faghihi G, Emami A, et al. Zinc sulfate for relief of pruritus in patients on maintenance hemodialysis. Ther Apher Dial. 2012 Apr. 16(2):142-5. [Medline].

  38. Cynamon HA, Andres JM, Iafrate RP. Rifampin relieves pruritus in children with cholestatic liver disease. Gastroenterology. 1990 Apr. 98(4):1013-6. [Medline].

  39. Ghent CN, Carruthers SG. Treatment of pruritus in primary biliary cirrhosis with rifampin. Results of a double-blind, crossover, randomized trial. Gastroenterology. 1988 Feb. 94(2):488-93. [Medline].

  40. Bergasa NV, Alling DW, Talbot TL, et al. Effects of naloxone infusions in patients with the pruritus of cholestasis. A double-blind, randomized, controlled trial. Ann Intern Med. 1995 Aug 1. 123(3):161-7. [Medline].

  41. Peer G, Kivity S, Agami O, et al. Randomised crossover trial of naltrexone in uraemic pruritus. Lancet. 1996 Dec 7. 348(9041):1552-4. [Medline].

  42. Terg R, Coronel E, Sorda J, Munoz AE, Findor J. Efficacy and safety of oral naltrexone treatment for pruritus of cholestasis, a crossover, double blind, placebo-controlled study. J Hepatol. 2002 Dec. 37(6):717-22. [Medline].

  43. Wolfhagen FH, Sternieri E, Hop WC, Vitale G, Bertolotti M, Van Buuren HR. Oral naltrexone treatment for cholestatic pruritus: a double-blind, placebo-controlled study. Gastroenterology. 1997 Oct. 113(4):1264-9. [Medline].

  44. Bergasa NV, Alling DW, Talbot TL, Wells MC, Jones EA. Oral nalmefene therapy reduces scratching activity due to the pruritus of cholestasis: a controlled study. J Am Acad Dermatol. 1999 Sep. 41(3 Pt 1):431-4. [Medline].

  45. Palma J, Reyes H, Ribalta J, et al. Ursodeoxycholic acid in the treatment of cholestasis of pregnancy: a randomized, double-blind study controlled with placebo. J Hepatol. 1997 Dec. 27(6):1022-8. [Medline].

  46. Roncaglia N, Locatelli A, Arreghini A, et al. A randomised controlled trial of ursodeoxycholic acid and S-adenosyl-l-methionine in the treatment of gestational cholestasis. BJOG. 2004 Jan. 111(1):17-21. [Medline].

  47. Bellmann R, Feistritzer C, Zoller H, et al. Treatment of intractable pruritus in drug induced cholestasis with albumin dialysis: a report of two cases. ASAIO J. 2004 Jul-Aug. 50(4):387-91. [Medline].

  48. Bellmann R, Graziadei IW, Feistritzer C, et al. Treatment of refractory cholestatic pruritus after liver transplantation with albumin dialysis. Liver Transpl. 2004 Jan. 10(1):107-14. [Medline].

  49. Hernandez-Nunez A, Dauden E, Cordoba S, Aragues M, Garcia-Diez A. Water-induced pruritus in haematologically controlled polycythaemia vera: response to phototherapy. J Dermatolog Treat. 2001 Jun. 12(2):107-9. [Medline].

  50. Morison WL, Nesbitt JA 3rd. Oral psoralen photochemotherapy (PUVA) for pruritus associated with polycythemia vera and myelofibrosis. Am J Hematol. 1993 Apr. 42(4):409-10. [Medline].

  51. Finelli C, Gugliotta L, Gamberi B, Vianelli N, Visani G, Tura S. Relief of intractable pruritus in polycythemia vera with recombinant interferon alfa. Am J Hematol. 1993 Aug. 43(4):316-8. [Medline].

  52. Gonçalves F. Thalidomide for the Control of Severe Paraneoplastic Pruritus Associated With Hodgkin's Disease. Am J Hosp Palliat Care. 2010 Mar 15. [Medline].

  53. Gutman AB, Kligman AM, Sciacca J, James WD. Soak and smear: a standard technique revisited. Arch Dermatol. 2005 Dec. 141 (12):1556-9. [Medline].

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