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Simple cases
Case 53
70-year-old woman with diffuse pruritus
History
Is the itch bad enough to wake you up?
It is terrible. It not only wakes me up, but I can't get to sleep without a pill.
This question lets you estimate the severity of the itch and the effect of the disease on the patient's quality of life.
Is anyone else in the family itching?
Is anyone else in the family itching?
This makes an infectious origin unlikely.
Were you on vacation before the itching started?
Yes, we spent some time on Sardinia on the coast.
This answer might suggest an infectious, perhaps parasitic, trigger, but it doesn't allow you to exclude other causes.
Do you have pets? Are they itching?
We don't have any pets.
Always ask about pets when a patient complains of pruritus. In this instance, if a pet were responsible, the husband would also be itching.
Have you noticed anything else on your skin besides the scratch marks?
I have had a few red spots on the buttocks and once in great while, a water-filled blister.
Very important question. Both of these findings are important and may not be present on the day of the examination.
Are you otherwise healthy?
I have some heart problems but my family doctor seems to have them under control. He checks my blood regularly. Everything was fine 3 weeks ago.
In this age group, many chronic problems such as renal disease, hepatic disease, anemia or diabetes mellitus can be associated with pruritus. The reassurance that the blood work was fine doesn't help us; we don't know what the family doctor checked.
Do you take any medications? Have you added any new ones recently?
I have been taking the same ACE inhibitor for years.
Many medications can cause pruritus, although there is usually an associated rash. Even a drug which has been tolerated for years can eventually trigger a reaction.
Lesion
Choose the right efflorescences:
The patient describes bulla, but often, as in this case, they can not be seen, because they have burst and dried up.
There are a few erythematous papules. These may precede the bulla in this disease by months.
A pustule has a pus-filled space; none are presence. They could develop with a secondary infection.
Erosions are superficial skin defects; in this disease they develop when bulla burst or are destroyed.
Diagnosis
Choose the right diagnosis:
The pruritus and urticarial papules are not typical for pemphigus vulgaris which also often has oral involvement. In rare circumstances, immunofluorescent studies are needed to separate the two diseases.
Insect bites have a more self-limited course. Bullous insect bite reactions are more common on the legs.
Prurigo features excoriated papules and a chronic course without blisters. A rare variant of this disease presents with a prurigo pattern but then evolves into displaying blisters. The immunofluorescent examination allows ready separation.
This is the most common autoimmune bullous disease in the elderly. The pre-bullous phase with pruritus and erythematous papules is frequently seen.
Therapy
Choose the right therapy(ies):
Not the standard treatment. Some patients benefit from long-term tetracycline or erythromycin but the mechanisms are unclear.
When multiple erosions are present, this is reasonable to reduce the risk of secondary infections.
In the early phase or when the disease is not widespread, topical corticosteroids are always worth a try.
Used when systemic corticosteroids fail to work, or to reduce their dose and thus side effects.
The mainstay of treatment, but coupled with many side effects, especially in elderly patients.
Test
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