Not everything that itches is allergy
Itching is one of the peculiar symptoms of lymphoma, kidney disease, liver ailments and cancer.
Anyone who experience relentless itching, even for a few days, knows how distracting and annoying it can be. But one can just imagine how infuriating it is for a person whose itch lasts weeks, months, or even years, as such discomfort can be debilitating. So it’s definitely no laughing matter. Aside from the fact that itching may herald a serious disease, it can be unbearable in its intensity.
Chronic itching — that is, itching lasting longer than six weeks — is often due to eczemas, psoriasis, or chronic hives. To many it is a common presenting symptom in patients without a preceding rash. The possible causes are more numerous and can include systemic problems like kidney disease, liver ailments and cancer.
Rash-free itching may also be secondary to neurologic (spine disease) or psychiatric conditions (such as substance abuse or obsessive compulsive disorder). Itching can also be of unknown cause (idiopathic). But regardless of the reason behind it, people with this symptom often suffer from sleeplessness, depression and anxiety.
For example, LP, a 60-year-old lady, manifested many brown-to-black, moderate-to-severely hard lumps scattered all over her body (prurigo), together with hair fall and thinning. LP had been to a lot of doctors who gave her a cocktail of topical and oral drugs that she applied for over three years, but none of which gave her sustained relief for her itching. Her blood tests revealed that she has an iron-deficiency anemia.
Itching is an unpleasant sensation related to a skin eruption or irritation that frequently provokes scratching. In contrast, generalized idiopathic pruritus, or severe itching, is often not associated with primary elementary skin lesions. Most importantly, generalized pruritus can represent the manifestation of a systemic disease. Some studies report that 14 to 50 percent of pruritic patients without a clear dermatologic cause have an underlying internal cause for their symptom, among which iron deficiency may play an important role.
Then there is VM, a 70-year-old mother of six diagnosed with a case of lymphoma. The reason she visited me was because of her severe, intractable itching. Itching without a rash is one of the peculiar symptoms of lymphoma. In some cases the itching starts before the diagnosis of lymphoma is made. It is often felt as a burning sensation occurring on a particular area of the skin, frequently on the lower legs. Itching can be extremely severe in these cases. The cause of this itch is not definitely known. It is believed that some blood cells release chemicals near the nerves of the skin and irritate these nerves. In lymphoma, itching has more importance, as it may be an indicator of a less favorable prognosis when associated with significant fever or weight loss.
Then there is LM, a 50-year-old woman who presented with intense pruritus and skin lesions. She had controlled hypertension and stage 4 chronic kidney disease. Examination revealed again the presence of a papulo-nodular eruption (large, hard, pigmented bumps on the limbs and trunk) known as prurigo. Prurigo nodularis is a dermatosis originating from pruritus and the persistence and progression of skin lesions are strictly correlated to scratching and rubbing. This is more frequent in middle-aged women. There is a tendency for symmetrical distribution, with a predilection for the extensor surfaces of the limbs and trunk. The face and the palms are seldom affected. Prominent features include crusting and excoriations with post-inflammatory pigmentation or sometimes, non-pigmented discoloration.
My purpose in writing this article is to raise awareness that while the skin itself, along with mucous membranes, is always the site of an itch, a systemic condition unrelated to the skin may be the cause.
Dr. Jeffrey Bernard, director of the Division of Dermatology at the University of Massachusetts Medical Center, credits itching with sometimes being the first symptom of a disease that may not show up for months — even years. For example, in one group of patients with a type of liver cirrhosis, six out of 10 first went to a doctor to be treated for itching.
Itching after a swim or a bath can herald a condition known as polycythemia rubra vera. Itching in the nostril has been linked, albeit rarely, to brain tumors. An intractable, burning-itch sensation may be a sign of lymphoma, and even AIDS may sometimes be signaled by itching.
Therefore, systemic causes must be considered, especially in elderly patients in whom pruritus is persistent and refractory to dry skin management and other nonspecific therapies. Therefore, a thorough history and physical examination is essential in the evaluation of chronic pruritus.
A multidisciplinary approach with a dermatologist, psychiatrist, and internist is required to prevent psychiatric morbidity and possible deterioration of quality of life in these patients. Also one of the most important tasks for the dermatologist is to thoroughly explain to the patient that they should keep the skin hydrated and avoid skin-drying activities such as hot, prolonged bathing, a dry environment, using alkali soaps, and wearing irritating fabric.
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