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Prurigo[L. the itch]

Papules induced by scratching

The term Besnier's prurigo is applied tothe chronic papular or lichenified form of

atopic eczema

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Nodular Prurigo(Prurigo Nodularis)

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Etiology

The cause is unknown

Emotional stress seems to be a

contributory factor in some cases

In 20% the condition starts after an insect

bite

There is increase in number of neutrophils,mast cells, Merkel cells and IL-31

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Clinically

Patients are mostly middle-aged to elderly

They complain of a long-standing history ofsevere, unremitting pruritus and they can

point out specific sites where they beganfeeling itchy

The patient's medical history may reveal

hepatic or renal dysfunction, local trauma tothe skin, infection, anxiety or otherpsychiatric condition

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The early lesion is red, and

may show a variable

urticarial component

All lesions are pigmented

Crust and scale may coverrecently excoriated lesions,

and there is an irregular

ring of hyperpigmentationimmediately around the

nodules

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The lesions are usually grouped, and

numerous, but vary in number

They usually develop initially onthe distal parts of the limbs & are

worse on the extensor surfaces

There are crises of pruritus of

intense severity

New nodules develop from time to

time, and existing nodules may remain

pruritic indefinitely, although some may

regress spontaneously to leave scars. The

disease runs a very protracted course

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Treatment

Local applications are of little value, butdirect injection of the nodules with a steroidsuch as triamcinolone is often helpful

Thalidomide is probably the most effective

treatment, if it is not contraindicated by therisk of pregnancy

Menthol, capsaicin cream, and topical

anesthetics are some other topical agentsused to reduce pruritus

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Cyclosporin, azathioprine and topical

capsaicin have been used with success insome cases

UV-B or PUVA may be beneficial for

severe pruritus A thorough assessment of the patient's

emotional state is desirable, and

tranquillizers may provide relief in some

cases

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Surgical Care

Cryotherapy with liquid nitrogenhelps reduce pruritus and flattenlesions

Pulsed dye laser therapy may helpreduce the vascularity of individual

lesions.

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Erythroderma

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It is a scaling erythematous dermatitis

involving 90% or more of the cutaneous

surface

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EtiologyThe most common causes of ED are(ID-SCALP(:

Idiopathic(red man syndrome) - 30%

Drug allergy(Allopurinol, aspirin,

anticonvulsants, barbiturates, captopril,cefoxitin, chloroquine, chlorpromazine,cimetidine, lithium, griseofulvin,nitrofurantoin, omeprazole) - 28%

Different types of eczema - 15%

Lymphoma and leukemia - 14%

Psoriasis - 8%

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Less common causes

Dermatophytosis

Lichen planus

Lupus erythematosus Pityriasis rubra pilaris

Pemphigus foliaceus and pemphigoid

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An increased skin blood perfusion occursresulting in heat loss and hypothermia andpossible high-output cardiac failure

Fluid loss by transpiration is increased.The situation is similar to that observed inpatients following burns (negative nitrogenbalance characterized by edema,

hypoalbuminemia, loss of muscle mass)

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A marked loss of exfoliated scales occursthat may reach 20-30 g/d. This contributes tothe hypoalbuminemia commonly observed in

ED. Hypoalbuminemia results, in part, fromdecreased synthesis or increasedmetabolism of albumin

Edema is a frequent finding, probablyresulting from fluid shift into the extracellularspaces

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Clinically

Patients may have a history of the primary

disease (e.g. psoriasis, atopic dermatitis)

or drug use

Pruritus is a prominent and frequent

symptom and commonly results in

excoriations. Malaise, fever, and chills may

occur

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Patients often present with

generalized erythema

Scaling appears 2-6 days

after the onset of erythema,

usually starting from flexures

When ED persists for weeks,

hair may shed; nails may become ridged

and thickened and also may shed

Periorbital skin may be inflamed and

edematous, resulting in ectropion

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Idiopathic ED is characterized by markedpalmoplantar keratoderma, dermatopathic

lymphadenopathy, and a raised level ofserum IgE and is more likely to persistthan other types

Residual signs of the original disease maybe found e.g.:

- Islands of sparing in PRP

- Few typical psoriatic plaques in psoriasis

- Papules or oral lesions of lichen planus

- Superficial blisters of pemphigusfoliaceus

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Investigations

If the cause of ED is in doubt, survey

patients for occult tumors

Primary disease may be evident by skin

biopsy

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Treatment

Discontinue all unnecessary medications.Carefully monitor and control fluid intake,since patients can dehydrate or go into

cardiac failure; monitor body temperature,since patients may become hypothermic

Apply tap waterwet dressings (made fromheavy mesh gauze); change every 2-3hours. Apply intermediate-strength topicalsteroids (e.g. betamethasone) beneathwet dressings

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Suggest a tepid bath (may be comforting)

once or more daily between dressing

changes. Reduce frequency of dressings

and gradually introduce emollientsbetween dressing applications as ED

improves

Use systemic antibiotics if signs ofsecondary infection are observed

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Antihistamines help reduce pruritus and

provide needed sedation

Systemic steroids may be helpful in some

cases but should be avoided in suspected

cases of psoriasis and staphylococcal

scalded skin syndrome

Ensure adequate nutrition with emphasis

on protein intake