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Probability diagnosis

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Psychological/emotional

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Old, dry skin (senile pruritus)

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Atopic dermatitis (eczema)

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Contact (allergic) dermatitis

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Varicella (chicken pox)

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Serious disorders not to be missed

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Cancer:

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  • lymphoma/Hodgkin

  • leukaemia: CLL

  • multiple myeloma

  • other cancer, e.g. mycosis fungoides

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Scabies (severe infestation)

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Chronic kidney failure

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Primary biliary cirrhosis/other causes (e.g. jaundice)

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Pitfalls (often missed)

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Pregnancy

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Tropical infection/infestation

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Polycythaemia rubra vera

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Polyarteritis nodosa

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Lichen planus

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Generalised sensitivity (e.g. fibreglass, bubble bath)

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Masquerades checklist

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Depression

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Diabetes

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Drugs (several types; see list)

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Anaemia (iron deficiency)

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Thyroid (hyper and hypo) disorders

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Spinal dysfunction (nostalgia paraesthetica)

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Is the patient trying to tell me something?

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Quite likely: consider anxiety, parasitophobia.

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Key history

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Enquire about nature and distribution of itching. Consider pregnancy, liver disease and malignancy of the lymphatic system, particularly Hodgkin lymphoma. A careful review of any drug history is important. Note any associated general symptoms such as fever.

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Key examination

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  • General examination of the skin, abdomen and lymphopoietic systems

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Key investigations

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Consider:

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  • FBE/ESR/CRP

  • urinalysis

  • pregnancy test

  • iron studies

  • kidney function tests

  • TFTs

  • blood sugar

  • chest X-ray

  • skin biopsy

  • stool examination (for ova and cysts)

  • lymph node biopsy (if present)

  • skin testing.

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Diagnostic tips

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  • The itching of polycythaemia may be triggered by a hot bath and lasts for at least 1 hour.

  • Pruritus can be the presenting symptom of primary biliary cirrhosis and may precede other symptoms by 1–2 years.

  • The itch of Hodgkin lymphoma (in 30%) may be unbearable.

  • Drugs that can cause pruritus: aspirin, barbiturates, morphine, cocaine, penicillin, other antibiotics, anticytotoxics.

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