PRURITUS ------------------------------------------------------ Please help with treatment suggestions for depressed 79yowm with "deep down itching". Medicines include Zanax, Ativan, and Paxil (most recent addition) for depression: Zestril, Inderal, Lasix, and Lanoxin for congestive heart failure: Ditropan for prostate problems (he has smoldering prostate cancer being watched): and, Claritin and Hydroxyzine for itching. Topically, he uses TAC in Lubriderm and Lac Hydrin Lotion plus I have recently added Ultravate Ointment. Rx for (non) Bullous Pemphigoid itch with Tcn resulted in a drug eruption as did trial with Erythromycin. He is also allergic to Polysporin and Neosporin and Pcn. I suspect an underlying allergy to sulfa meds as well and have requested his LMD DC Lasix and Zestril to substitute Edecrin. He is being brave and "trying to live with it" but I would like to give him the magic cure----ANY IDEAS? Maida Burrow MD --------------- Clearly, your patient has an extremely complex history with multiple possible etiologies. There are a number of therapeutic avenues to explore. Consider: 1. Minimize all drugs that are not vital to the person's health 2. Make sure the depression is being adequately addressed 3. Bullous pemphigoid can be associated with severe pruritus. Consider systemic corticosteroids, methotrexate, azathioprine, and similar agents 4. Always ask yourself on a periodic basis, am I missing another systemic condition responsible for this pruritus 5. When all else fails, consider phototherapy (UVA/UVB or PUVA), other antiinflammatory agents (dapsone, sulfasalazine, etc.), or thalidomide. 6. Let the patient know you are interested or send them to someone who is interested. Alan Fleischer MD ----------------- I have an elderly gentleman with Polycythemia Vera who itched uncontrollably for two years, despite appropriate Rx. He also had a rash which, though suspicious, has never been shown to be CTCL on multiple bx. I tried many different topical and oral treatments. I did not try UV which might be helpful in your fellow, because my pt did not want it. Ultimately prednisone has done the job. Started at sufficient dose to see if there was a salutory effect, eg 20mg bid and tapered to a safer 10mg qod, the patient is the happiest he has been in two years. and the rash is no longer visible. Jerry Eisner MD ---------------- 1. Make sure he is not iron deficient, [I] have seen several colon CA's present as itching, especially on the back. 2. I have found UVB very helpful when all else fails, several times when skin biopsy has shown scattered eosinophils and the pathologist suggested drug eruption. LJ Gregg MD ----------- COMMENTS OF KATHRYN ANNE ZUG, M.D. 3 recent anecdotal cases come to mind regarding intractable itching: 1) 54 yo women with remote history of transfusion--not offered by hx. PE showed only excoriations. Turned out to be HIV positive, to all our surprise. She was itching for 1 1/2 years. 2) 2 patients each over 70 with paraproteinemias but not yet able to diagnose a leukemia or lymphoma. Prednisone at higher doses worked in one, the other is now itch free on cytoxan. Their itch was intractable and depressingly distressing. 3) Patient with minimally increased LFTs, Hep B negative, Hep C positive. Doing well on interferon. --Keep looking, keep thinking! Kathryn Anne Zug MD ------------------- r/o polycythemia vera, renal failure, liver disease - also look for low B12 or low ferritin. UV light often works where all else fails -- I'd try him with 10 J of UV-A and maybe 40 mJ of UV-B, increasing by 5-10 mJ per Rx as tolerated. PUVA works for prurigo nodularis. ASA is somewhat helpful in polycythemia. If depression is at the root of his itch the Paxil may start to help after a few weeks. Please let us know how he turns out. K.C. Smith, MD, FRCPC --------------------- Organic cause of itching need to be ruled out, including occult causes such as paraproteinemia, iron deficiency, hypercalcemia, early lymphoma, early bullous pemphigoid, etc. But his depression is an obvious problem and until it is adequately treated (i.e. adequate time on an adequate dose plus counselling), his pruritus may be intractable. If his internist or cardiologist approve after reviewing his EKG, low dose trazodone (e.g. starting at 10mg) qhs may be better tolerated in the elderly than doxepin which is more commonly used by dermatologists. Also, the trazodone at bedtime may counter the sleeplessness associated with the Paxil (paroxetine). His poly-allergy is difficult to interpret if the reactions were cutaneous, and may reflect a tendency to urticaria and dermatographism that can be subtle in the elderly. The antihistamine effects of the trazodone may thus be helpful, providing the patient does not get orthostatic or other symptoms. Finally, UV therapy, especially PUVA or possibly combined UVA/UVB could also be considered. John Melski, MD --------------- Intractable itching has also been associated with lymphoma (esp. Hodgkin's) and occasionally other tumors. This is especially true of patients unresponsive to any topical therapy. I would recomend a chest x-ray as a start, and keep it in mind at follow-up visits (i.e., check adenopathy, liver edge etc.). Obviously, biopsy any adenopathy. Larry Meyer MD -------------- I need some help from this illustrious group of Dermatologists for a sweet 70 year old lady who has had a five month history of severely pruritic excoriated papules that begin with small blisters(I have yet to see them) by history. They are located on her scalp, upper chest,arms, elbows,gluteal cleft area and around her knees. She has seen 2 other derms who felt she had papular urticaria and contact dermatitis but she was totally refractory to oral antihistamines,topical steroids and lindane. A skin biopsy suggested that these were due to insect bites. I felt that she had Dermatitis Herpetiformis and began her on 100mg Dapsone bid and she promptly cleared and stopped itching. Unfortunately she developed serum sickness manifested by jaundice,malaise,myalgia, fever and elevated liver enzymes/bilirubin. Lab also revealed an eosinophilia of 7% and anemia. An immunoflourescence bx of normal skin was negative. Gluten free diet has not been helpful as she has again worsened since stopping the Dapsone. I still feel she has DH but my question is am I overlooking something and what is your suggested treatment for DH in a person allergic to sulfa meds. W H Burrow MD -------------- It sounds possible that this woman has Bullous Pemphigoid. I assume the biopsy demonstrated eosinophils, compatable with both bites and BP. BP also can respond to dapsone. It is also more common than DH. I would suggest a perilesional biopsy for IF, as well as serum for IIF. Both anti-endomesial and anti-basement membrane antibodies could be requested if you feel DH is likely. Good luck. Larry Meyer ----------- There are several considerations here. One: is this DH? Where the biopsy is taken is important. Normal skin distant to lesional areas may be DIF negative in DH- therefore perilesional skin is the best. Without a characteristic history, DIF, biopsy, DH is not likely. Two: the description and biopsy also sound consistent with bullous pemphigoid (urticarial, vesicular types), linear IgA, possibly vasculitis, reactions to insect bites/arthropods or to a parasite (helmnithic), EBA. Three: Dapsone responsiveness is not diagnostic for DH even with similar appearing lesions: various vasculitidies, lupus, Sweet's, EED, etc., are sensitive. Four: my experience is that very few patients (without great motivation or a bit of obsessive-compulsive personality) can/will strictly follow a gluten-free diet and their sensitivity to violating GFD varies greatly. Five: the reaction to dapsone is possibly in the setting of a partial/full G6PD (or methemoglobin reductase) deficiency. I have seen patients who have had this severe hypersensitivity with hemolysis, hyperbilirubinemia (more common in G6PD def), mono-like symptoms, with normal G6PD. Six: there is _not_ cross-reaction with sulfapyridine (also less hemolysis, neuropathy, efficacy) and dapsone and some DH patients do very well on sulfapyridine (Jacobus Pharmacy). Also: NSAIDs usually cause DH to appear/flare in those with it. If the DIF was not perilesional I would repeat it. If negative consider the other diagnoses, if positive consider sulfapyridine. David J. Altman, MD, PhD Dermatology Branch, NCI, NIH ---------------------------- I'll still wager that there is an element of lsc there...you might try 1)securing one area with an occlusive bandage and 2) try some intralesional cortisone. Steven D. Emmet, M.D. --------------------- Strongly consider that this may represent the first signs of dibetic neuropathy. This is a location that may be affected early in the course of nerve damage. Excellent control of his diabetes may not reverse any of the nerve damage, but may slow the rate of progression. I've tried lots of agents for localized pruritus. On an anecdotal basis I might suggest the following that have worked for a few of my patients: Doxepin 25 to 100 mg po qhs Klopopin 1 to 3 mg bid as tolerated If vascular compromise is suspected, consider trental 400 mg tid to increase local circulation. Alan Fleischer MD ----------------- I also wonder somewhat about BP. Would you consider Tetracycline, 250 QID, and Niacinamide. Well tolerated, safe, and possibly effective. Elliot Puritz ------------- Deja vu! If you changed the patient's description from female to male, you would almost exactly match a patient that I saw 2 months ago. My PA had obtained a bx for H&E with the same result as yours, and he had also taken a bx of normal skin for DIF, which was negative. When I reviewed the pt with him, I thought he might have linear IgA disease, so I took a bx for DIF from perilesional skin. The results were classic for bullous pemphigoid, and no IgA was found. I tried him on TCN and niacinamide unsuccessfully, but he rapidly cleared on prednisone 30mg qAM. He has now been tapered to 10 mg QOD without recurrence. Druid71@aol.com ---------------- Several ideas on DH-like pruritis (based on recent clinical cases of mine) : l. A visitting German dermatologist described DH-like insect-bite-histo in older than middle-age woman totally responsive to Dapsone, which they call Subacute Prurigo, or some similar descriptive terminology. I have had two women in their 40's who totally fit the picture, hence, was relieved to be able to give their disease a name and treatment. One of them is being evaluated for thyroid disease ( DH associated thyroid carcinoma?). 2. Cholestyramine worked 100% in a patient with Dapsone Hepatitis and DH. The reference is the Shelley's book. 3. Beware of the odd DH, or possibly any DH, as a sign of internal malignancy. I recently had a patient with a huge cystic neck mass , Scca. He had the mass for many years, but finally came in for his intractable pruritis. He had DH totally responsive to Dapsone. I shall report on the status of his DH after his surgery, radiation , and whatever. Parenthetically, I am hoping the oncologists don't wipe out his immune system which may have kept this grapefruit sized carcinoma in check for many years . Might the aromatic retinoids be a good addition to his therapy? Diane Thaler ------------ I would appreciate any suggestions any of our members might make in the management of my Pediatric neighbor who has intractable severe localized pruritus of the dorsal surface of the feet for six weeks. Except for evidence of obvious excoriations there is no abnormality of the skin. He is 60 years old and has known elevated uric acid levels controlled with allupurinol for 8 years.He also has nasal allergies which he treats with claritin D.In November of 1995 his blood sugar ws 430, then 190mgm% and after lossof 15 pounds it has stabilized without any medication to about 138mgm%. A completeCBC with differential, Smac 20 and urinalysis are normal. His internist gave him elavil at night which helped for about a week.He is using ice cold iced tea soaks, sarna,5%xylocaine ointment,1 and 2 and one half percent pramasone cream, dermacaine(works best but believe he is becoming sensitized).in addition mild antiipruritics such as hydroxyzine. A neurologic workup with EMG was normal although early neuropathy was suspected because of associated recent onset of plantar hyperhidrosis not helped with use of drysol. We have suggested an MRI and he is seeinga Pain specialist(on suspicion that the itch and pain fibers in his case are involved. I asked him to stop his allopurinol and claritin D yesterday justin case the itching might be a reaction to those medications.Thanks for your help. Joel C. Fink M.D ----------------- I would use zostrix...its perfect for this...qid initially and bid after the itching is controlled...and! give him some innocuous cream to rub in to take care of the lichen simplex chronicus 'itch-scratch' cycle. Steven D. Emmet, M.D. --------------------- We did use zonalon and zostrix burned so badly the patient wouldn't continue its use. Joel Fink MD ------------- The recent discussions about the DH-like pt. with the insect bite like pathology, but negative DIF reminds me of an annoying fall/winter problem we have here on the eastern side of the northern Rockies, Cheyletiella dermatitis. This condition has been reported worldwide, but the largest reported group of cases I've heard of was also on the eastern slope of another mountain range, the Cascades (Cheyletiella dermatitis: a report of fourteen cases. Lee: Cutis (1991 Feb) 47(2):111-4). The condition is caused by a pet (dog, cat, rabbit etc.) carried, non-burrowing mite. Many of my cases have lesions quite similar to DH (although the distribution varies) and the pruritus is extremely severe...much like scabies. It tends to strike the 40ish female in the family first and can last for months unless the diagnosis is suspected and the pet is removed or treated. The condition on the pet varies from severe scratching and hair loss to completely asymptomatic and subclinical. Some veterinarians are familiar with the condition, but many are not and have trouble making the diagnosis. If this diagnosis is suspected we insist that the pet be treated (usually with ivermectin), even if the veterinarian cannot confirm the diagnosis. This has lead to some very dramatic "cures" in otherwise baffling cases. I do not know how this condition would respond to dapsone, but I suspect there are patients out there who've been tried on dapsone out of desperation if this diagnosis was not considered. Anyone else out there live in an area where this condition is a problem? Kip Cullimore, MD ------------------ I've got a couple of patients with delusions of parasitosis doing well on Risperdal (rispiridone - Janssen) - similar to Orap but less sedation and less worry about extrapyramidal effects. I've had a couple of others with difficult lichen simplex chronicus responding well to Risperdal 1 - 3 mg hs for the past few months, and I have a drug rep with median nail dystropy secondary to cuticle picking improving nicely on Risperdal 0.5 mg / hs. KC Smith MD FRCPC Niagara Falls ON ----------------