Aquagenic pruritus: Itch Clinic
Multiple scratch-induced lesions on the back of a patient with severe itch involving the whole body
Itch is the major source of morbidity in patients attending our clinics. Patients with severe and intractable itch are referred by dermatologists to the Itch Clinic. We aim to improve treatment for our patients suffering from severe and chronic itch through a holistic approach. The scope of management of the clinic consists of the following conditions:
- Itch involving the whole body that is not due to an apparent underlying skin problem
- Itch involving a particular area of the body that is not due to an underlying skin problem
- Severe and chronic itch that is not responsive to treatment
The clinic runs weekly on Friday afternoons and takes referrals from dermatologists. It is located at Clinic H on the second floor of the National Skin Centre. Clinical indicator:
- Mean percentage reduction in itch score between the first and final visit to the Itch Clinic
- To assess the severity of symptom in our patients, we ask patients to rate the intensity of itch they felt over the past 1 week on a 10-point numerical scale.
- To monitor the progress of our patients, we determine their itch scores at the first and final visits to the clinic. We subsequently calculate the mean percentage reduction using these 2 values.
Aquagenic pruritus
Aquagenic pruritus is a skin condition characterized by the development of severe, intense, prickling-like epidermal itching without observable skin lesions and evoked by contact with water. Presentation varies from person to person. Some people have discrete attacks, which can last between 10 and 120 minutes while others are symptomatic almost constantly due to atmospheric humidity levels and/or sweating. Itching most frequently occurs on the legs, arms, chest, back, and abdomen, though it can also occur elsewhere. Itching on contact with water that also includes hives is known as aquagenic urticaria.
The exact mechanism of the condition is unknown. Some studies have suggested the itching occurs in response to increased fibrinolytic activity in the skin, inappropriate activation of the sympathetic nervous system, increased activity of acetylcholinesterase, or an increase in mast cell degranulation that releases histamine and other chemicals into the body. No definitive medical test is known for aquagenic pruritus. Rather, diagnosis is made by excluding all other possible causes of the patient's itching, including polycythemia vera. Since pruritus is a symptom of many serious diseases, it is important to rule out other causes before making a final diagnosis.
Treatment:
- Beta-Alanine, a nonessential amino acid and freely available as a nutritional supplement in many countries, has been found to suppress or significantly reduce the symptoms in many cases. Anecdotal evidence indicates that it is commonly consumed in doses of 750 mg to 2 grams before water contact. A study found that a dose of 2 grams twice per day led to a "dramatic and sustained improvement" of symptoms in a 13-year-old male patient, allowing him to comfortably shower, exercise, and swim.
- Other treatment is usually focused on topical itch management. This can be effected by the application of hot water at the end of a bath or shower, antipruritic lotions or creams such as lotion containing capsaicin, using phototherapy, or the application of hot or cold packs to the skin after water contact. Paradoxically, hot baths or showers help many patients, possibly because heat causes mast cells in the skin to release their supply of histamine and to remain depleted for up to 24 hours afterward.
- H1 and H2 blockers, such as loratadine, doxepin, or cimetidine, have historically been the first line of pharmacological treatment, but not all people find relief with these medications. When antihistamines do work, loratadine seems to be the most effective for mild cases and doxepin most effective for more severe cases. Naltrexone, hydrocortisone, or propranolol may relieve itching for some people.
Itchy Skin (Pruritus)
Itchy skin is an irritating sensation that makes you want to scratch. It's also called pruritus (proo-RIE-tus). Itchy skin is often caused by dry skin and is common in older adults, as skin tends to become drier with age. Depending on the cause of your itchiness, your skin may look no different than usual or it may be inflamed, rough or have bumps. Repeated scratching can cause raised thick areas of skin that might bleed or become infected. Many people find relief with self-care measures such as moisturizers, gentle cleansers and lukewarm baths. Long-term relief requires identifying and treating the cause of itchy skin. Common treatments are medicated creams, moist dressings and anti-itch medicines taken by mouth.
Symptoms - Itchy skin can affect small areas, such as the scalp, an arm or a leg. Or it can cover the whole body. Itchy skin can occur without any other noticeable changes on the skin. Or it may come with:
- Inflamed skin
- Scratch marks
- Bumps, spots or blisters
- Dry, cracked skin
- Leathery or scaly patches
Sometimes itchiness lasts a long time and can be intense. As you rub or scratch the area, it gets itchier. And the more it itches, the more you scratch. Breaking this itch-scratch cycle can be difficult. See your health care provider or a skin disease specialist (dermatologist) if the itching:
- Lasts more than two weeks and doesn't improve with self-care measures
- Is severe and distracts you from your daily routines or prevents you from sleeping
- Comes on suddenly and can't be easily explained
- Affects your whole body
- Comes with other symptoms, such as weight loss, fever or night sweats
Pruritus (Itchy Skin)
Pruritus is the medical term for itchiness. The condition causes you to feel the need to scratch your skin to get relief. There are several possible causes for pruritus that include an underlying medical condition, contact with an irritant or a reaction to a medication. Treatment varies based on what caused your skin to itch.
What is pruritus? - Pruritus is a medical term that means itching. It refers to a feeling or sensation on your skin that you want to scratch. Pruritus can be painful or irritating and could be localized to one area of your body or spread throughout several areas. Pruritus can be a symptom of an underlying condition. It has many possible causes; the most common being contacting an allergen, dry skin, pregnancy and your body’s reaction to a medication. Pruritus can be chronic if your itching persists for six weeks or more.
What are the types of pruritus? - There are several different types of pruritus categorized by the cause of itchiness and the location of the itch on your body. Some of the most common types of pruritus include:
- Brachioradial pruritus: Itching of the upper arm caused by nerve damage.
- Nocturnal pruritus: Itching that occurs at night with several possible causes that include a reaction to your body’s natural functions, a reaction to a medication or contacting a skin irritant.
- Pruritus ani: Itching of the skin surrounding your anus caused by hemorrhoids, an infection or a skin irritant.
- Senile pruritus: Itching caused by changes to your skin that affects people over the age of 65.
- Uremic pruritus: Itching occurs as a symptom among people diagnosed with renal disease who receive dialysis.
What’s Causing Your Itchy Skin (pruritis)?
Itchy skin or pruritis can result from conditions like eczema or dermatitis. Less commonly, it can stem from more serious conditions, including kidney failure and liver disease. Itchy skin is an irritating and uncontrollable sensation that makes you want to scratch to relieve the feeling. Possible causes for itchiness include internal illnesses and skin conditions. Some causes of itching affect just one area, while others can make you feel like your whole body is itching. In some cases, itching may also be worse at night. Many causes of itching are not a cause for concern, and they respond to over-the-counter treatments, moisturizers, or home remedies. However, it’s best to contact a doctor if the cause isn’t obvious, if the itching is severe or persistent, or if you are concerned about it. They can treat any underlying conditions and provide medications to relieve discomfort.
Causes - Itchiness can be generalized (all over the body) or localized to one small region or spot. The possible causes are numerous and varied. Itching may be a result of something very serious, such as:
- kidney failure
- liver disease
- thyroid disease
- lymphoma
- diabetes (uncommon)
Skin conditions - Many common skin conditions can cause itchy skin. The following can affect any area of skin on the body:
- Dermatitis. Dermatitis is an inflammation of the skin.
- Eczema. This is a chronic skin disorder that includes itchy, scaly rashes.
- Psoriasis. This autoimmune disease causes skin discoloration and irritation, usually in the form of plaques.
- Dermatographia. With dermatographia, pressure on the skin leads to elevated levels of histamine that cause a raised, red, itchy rash.
- Hives. These are itchy, raised, discolored welts on the skin that are usually caused by an allergic reaction.
- Ringworm. Ringworm is a fungal infection of the skin.
- Shingles. This infection is caused by the same virus that causes chickenpox.
- Allergies. Skin can become itchy due to an allergic reaction to something you ate or touched.
Your Skin, Pruritus, and Itching
Pruritus simply means itching. It can be associated with a number of disorders, including dry skin, skin disease, pregnancy, and rarely, cancer. Who Gets Pruritus? - Anyone can get pruritus but certain groups of people are more susceptible to the condition, including:
- People with seasonal allergies, hay fever, asthma, and eczema
- People with diabetes
- People with HIV/AIDS and various types of cancer, especially those with leukemia or lymphoma
- Pregnant women
- The elderly
How Is Pruritus Treated? Finding the cause of the itching and treating any underlying skin disease is the first step in solving pruritus. If a drug reaction is suspected, switching to a different medication may be helpful to reduce the itching. However, most drug reactions have a rash along with itching. The best way to prevent pruritus is to take care of your skin. To protect skin:
- Use skin creams and lotions that moisturize your skin and prevent dryness.
- Use sunscreens regularly to prevent sunburns and skin damage.
- Use mild bath soap that won't irritate your skin.
- Take a bath or shower in warm -- not hot -- water.
- Avoid certain fabrics, such as wool and synthetics, that can make skin itch. Switch to cotton clothing and bed sheets.
- Since warm, dry air can make skin dry, keep the thermostat in your house down and use a humidifier.
- To relieve itching, place a cool washcloth or some ice over the area that itches, rather than scratching.
Your doctor may also prescribe medication to treat pruritus, including antihistamines and topical steroids. Rarely, steroid pills and antibiotics may also be needed.
What Is Pruritus?
"Pruritus" is the clinical name for the symptom of itching. There are many causes of pruritus. They include dry skin (xerosis) and skin conditions such as eczema (an inflammatory skin disease also called atopic dermatitis), allergic skin reactions (contact dermatitis), and systemic conditions, such as diabetes and blood cancers. This article will discuss what causes pruritus, symptoms, diagnosis, treatment, and prevention.
Pruritus Causes - There are many causes of pruritus. A common cause of pruritus is xerosis, especially in older adults and in people who live in colder climates. Other causes include:
- Skin conditions such as eczema and psoriasis (an autoimmune skin disorder)
- Allergic contact dermatitis from exposure to nickel, poison ivy, latex, laundry detergents/soaps, and other irritants
- Viral infections such as human immunodeficiency virus (HIV), herpes zoster (shingles), viral hepatitis
- Bacterial infections such as folliculitis (infection of the hair follicles)
- Parasitic infestation such as scabies
- Insect bites
- Diabetes
- Blood cell cancer and other blood disorders, such as Hodgkin's lymphoma (a cancer of the lymphatic system) and polycythemia vera (a blood disorder with overproduction of red blood cells)
- Systemic conditions such as urticaria (hives), hyperthyroidism (overactive thyroid), iron deficiency anemia, uremia (high levels of waste products in the blood, seen in kidney failure), and cholestasis (impaired bile flow)
- Medications such as opioids, antimalarial drugs
- Allergic food triggers, including reactions to shellfish, nuts, and nitrates
- Heat exposure
- Pregnancy
- Neurological causes such as notalgia paresthetica (a sensory disorder causing an itch below the left shoulder blade)
Pruritus can occur as a localized or systemic symptom based on the underlying cause. The underlying mechanism of your pruritus depends on the precipitating cause, and no single mechanism explains all forms of pruritus. In allergic reactions, the chemical histamine is released by mast cells and triggers itchiness.2 But in nonallergic causes of pruritus, it may be due to other chemicals. For example, serotonin appears to be a key component of pruritus in systemic conditions such as polycythemia vera, uremia, cholestasis, and lymphoma.
Diagnosing & Treatment of Itchy Skin
Diagnosing the cause of itchy skin starts with a physical exam and questions about your medical history. If your health care provider thinks your itchy skin is the result of a medical condition, you might have tests, including:
- Blood test. A complete blood count can provide evidence of an internal condition causing your itch, such as anemia.
- Tests of liver and kidney function. Liver or kidney disorders and thyroid conditions, such as hyperthyroidism, can cause itching.
- Chest X-rays. A chest X-ray can show if you have enlarged lymph nodes, which can go along with itchy skin.
Treatment - Itchy skin treatment focuses on removing the cause of the itch. If home remedies don't ease your symptoms, your health care provider may recommend prescription medicine or other treatments. Controlling itchy skin symptoms can be challenging and may require long-term therapy. Options include:
- Corticosteroid creams and ointments. If your skin is itchy and inflamed, your health care provider may suggest applying a medicated cream or ointment to the affected areas. You might then cover the treated skin with damp cotton material. Moisture helps the skin absorb the cream and has a cooling effect.
- If you have severe or long-term itching, your health care provider might suggest this bedtime routine: Bathe in plain lukewarm water for 20 minutes, and then apply triamcinolone .025% to 0.1% ointment to the wet skin. This traps the moisture and helps the medicine absorb. Then put on pajamas. Repeat this routine at bedtime for several nights.
- Other creams and ointments. Other treatments that you apply to your skin include calcineurin inhibitors, such as tacrolimus (Protopic) and pimecrolimus (Elidel). Or you may find some relief with topical anesthetics, capsaicin cream or doxepin cream.
- Oral medicines. Antidepressants called selective serotonin reuptake inhibitors (SSRIs) may be helpful in easing some types of long-term itch. Examples of SSRIs include fluoxetine (Prozac) and sertraline (Zoloft). Another option is a tricyclic antidepressants, such as doxepin, You may not feel the full benefit of some of these medicines until 8 to 12 weeks after starting treatment.
- Light therapy (phototherapy). Phototherapy involves exposing your skin to a specific type of light. This can be a good option for people who can't take oral medicines. You'll likely need a few phototherapy sessions, until the itching is under control.
Rollerball device to relieve eczema itch
Koh Bei Ning’s rollerball anti-itch device for eczema skin is becoming a reality with her Kickstarter and website launch. (Photo: Koh Bei Ning)
Imagine suffering from eczema and endless itchy skin. And then imagine you create a nifty rollerball device that relieves eczema itch – and it gets picked up by the James Dyson Award for a national innovators contest. Imagine you get so much interest that you crowdfund on Kickstarter to make your rollerball invention a reality. Koh Bei Ning doesn’t need to imagine. This was her dream and it’s becoming a reality.
Koh suffers from atopic dermatitis (its common name is eczema) and as part of her final-year thesis at the National University of Singapore (NUS) Division of Industrial Design (DID), she created a rollerball itch relief device that works as a gentle alternative to scratching. She submitted her design as an entry to the James Dyson Award, an international design innovation competition which highlights design engineers at the start of their careers. Her rollerball device became the Singapore runner-up.
Koh’s invention is a rollerball mechanism with a textured ball that rolls over the skin. It uses repetitive downward pressure on itchy skin to provide relief through the texture, while minimising force on the skin. For sufferers of eczema, this motion reduces tearing of already inflamed and irritated skin and avoids further irritation from fingernails when scratching. Doors opened for her after her invention won accolades, which enabled her to share how her eczema itch relief rollerball, now called Rollo, works. “I have been given many valuable opportunities such as participating in Prototypes for Humanity, an exhibition in Dubai which gathers 100 student innovations,” she said.
related:
