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Last updated: 30 March, 2020 15:59pm

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Generalised Pruritus – Information for GPs

Definition

Pruritus is defined as the desire to scratch. When generalised it affects most or all of the body. Can lead to anxiety, depression, skin damage etc.

Causes

  • Dry skin, eczema, scabies are commonest – examine the skin very carefully

If there is no rash except excoriations consider:

  • Anaemia, especially iron deficiency
  • Uraemia
  • Cholestasis, autoimmune liver disease
  • Hypo and hyper-thyroidism
  • Lymphoma – itch may precede diagnosis by several years
  • Carcinoma – especially in middle aged/elderly
  • Psychological

Exclude red flag symptoms

  • Check for lymph nodes (cervical, axillae and groins) and organomegaly i.e. hepatomegaly, splenomegaly
  • A full general examination is essential, repeated if symptoms don’t settle

Management

  • Strong advice not to scratch is very important due to the itch/scratch/itch cycle – “the more you scratch the more you itch”. Also advise to keep cool, keep nails short and smooth. Cotton gloves at night can help to avoid skin damage. Luke warm baths or showers or cool flannels can help. Applying emollients can help to reduce itch due to their cooling effect. Distraction can help many too.
  • Standard emollients and soap substitutes are essential – see Emollients Guidance for full information on prescribing
  • If an emollient alone does not provide adequate relief, consider a trial (100g) of an emollient with an active ingredient for example menthol 0.5% (e.g. Dermacool®) or 1% in aqueous cream or topical crotamiton (Eurax®)
  • The use of potent topical steroids should be discouraged unless there is active eczema • Sedating antihistimines: Chlorphenamine 8mg nocte or tds Hydroxyzine 25-50mg nocte increased if appropriate to 25mg 3-4x daily (please consider MHRA advice re: hydroxyzine). Care with sedative antihistamines – warn re: drowsiness especially in elderly
  • Alternative treatments – beneficial for any associated anxiety
    Amitriptyline
    Sertraline See BNF for additional prescribing information

Referral criteria

Unresponsive to treatments and no underlying cause found.

Investigations prior to referral

  • FBC, U/E, LFT, TFT, ferritin, ESR/CRP
  • CXR, urinalysis if above negative
  • Consider checking B12/folate depending on FBC result

Information to include in referral letter

  • Investigations and treatments already tried
  • Relevant past medical/surgical history
  • Current regular medication
  • BMI/Smoking status

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