Materiały źródłowe

• #1 Pruritus: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p55.html

  Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. […] In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. […] The differential diagnosis of pruritus is broad and includes acute and chronic (i.e., at least six weeks of symptoms) presentations. Primary and secondary skin lesions suggest dermatologic etiologies of pruritus.

• #1 Itchy skin (pruritus) – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/itchy-skin/diagnosis-treatment/drc-20355010

  Diagnosing the cause of itchy skin starts with a physical exam and questions about your medical history. If your health care provider thinks your itchy skin is the result of a medical condition, you might have tests, including: […] A complete blood count can provide evidence of an internal condition causing your itch, such as anemia. […] Liver or kidney disorders and thyroid conditions, such as hyperthyroidism, can cause itching. […] A chest X-ray can show if you have enlarged lymph nodes, which can go along with itchy skin. […] Your health care provider is likely to begin with your medical history and to ask you some questions, such as: When did you begin experiencing symptoms? […] Are tests needed to confirm the diagnosis? […] What are other possible causes for my symptoms? […] What is the best course of action?

• #2 Pruritus: Causes & Treatments for Itchy Skin

  https://my.clevelandclinic.org/health/diseases/11879-pruritus

  Pruritus is the medical term for itchiness. The condition causes you to feel the need to scratch your skin to get relief. There are several possible causes for pruritus that include an underlying medical condition, contact with an irritant or a reaction to a medication. Treatment varies based on what caused your skin to itch. […] Pruritus can be a symptom of an underlying condition. It has many possible causes; the most common being contacting an allergen, dry skin, pregnancy and your bodys reaction to a medication. Pruritus can be chronic if your itching persists for six weeks or more. […] Pruritus is very common and will affect everyone during their lifetime. The severity and frequency are different for each person. […] Your provider will diagnose your condition and offer treatment options based on what caused your skin to itch.

• #2 Pruritus: Causes & Treatments for Itchy Skin

  https://my.clevelandclinic.org/health/diseases/11879-pruritus

  To diagnose pruritus, your provider will physically examine your skin and will gather more information about your symptoms and your medical history. […] Your provider might offer tests to confirm a diagnosis. Testing can help determine what caused your symptoms. […] Treatment for pruritus is unique to each person and varies based on what caused your symptoms. […] Your provider may prescribe medications to treat pruritus, including antihistamines, topical steroids or oral steroids. […] The length of time you’ll have pruritus depends on the cause of your itchy skin. […] Talk to a healthcare provider about treatment options to relieve your symptoms. […] Contact your healthcare provider if you have itchiness that lasts longer than a couple of weeks.

• #3 Itch, pruritus

  https://dermnetnz.org/topics/pruritus

  Pruritus is the medical term for itch. Itch is an unpleasant sensation on the skin that provokes the desire to rub or scratch the area to obtain relief. Pruritus is often a symptom of an underlying disease process such as a skin problem, a systemic disease, or abnormal nerve impulses. […] The first steps of evaluation of an itchy patient are medical history and examination. A thorough history can identify constitutional symptoms that may point towards an underlying systemic disease. A careful examination can identify dermatological causes for the itch (eg scabies, lichen simplex, pemphigoid) or evidence of chronic skin changes related to the itch. Patients without primary skin lesions and little evidence of chronic scratching should be investigated for systemic, neuropathic and psychogenic causes.

• #3

  https://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/dermatology/pruritus-itch/

  Pruritus or itch is defined as an unpleasant sensation of the skin that provokes the urge to scratch. It is a characteristic feature of many skin diseases and an unusual sign of some systemic diseases. Pruritus may be localized or generalized and can occur as an acute or chronic condition. Itching lasting more than 6 weeks is termed chronic pruritus. Itching can be intractable and incapacitating, as well as a diagnostic and therapeutic challenge. […] A detailed history is the single most important step toward diagnosing the cause of itching. This should include information on the onset, extent (generalized vs. localized), severity, type of itch, aggravating and alleviating factors, diurnal and seasonal variations, bathing, occupation, hobbies, medication history and allergies, and past medical and surgical history.

• #4 Diagnosis

  https://www.itchforum.net/for-patients/diagnosis/

  A number of itchy skin conditions can easily be diagnosed. However, it becomes more difficult with pruritus, which occurs in apparently normal skin or secondary lesions caused by scratching as a result of systemic diseases. If the pruritus does not stop at all, then the cause must be examined more closely. A detailed medical diagnosis, in which the skin and the internal organs are examined thoroughly, is then important. It is also important for the doctor to know when the pruritus began, whether there were any illnesses in the past and which medication was or is being taken. Also quality, intensity and frequency of pruritus are factors that play a role in the diagnosis. As pruritus is subjective and cannot be measured objectively, the symptom is often assessed via a questionnaire that you as a patient fill out. An individual and detailed anamnesis, clinical examination as well as interdisciplinary, laboratory chemical and radiological diagnostics are of great importance in the assessment of chronic pruritus. The clinical examination includes a complete inspection of the entire skin, including mucous membranes, scalp, hair, nails, and anogenital region. An X-ray image of the thorax and a sonography of the abdomen can provide indications of a possible malignant disease. In addition, the integration of other specialist disciplines (neurology, psychiatry, general medicine, allergology, dermatology, internal medicine [gastroenterology, hepatology, endocrinology, haematooncology], urology, gynaecology, etc.) plays an important role in diagnosis finding. The identification and treatment of underlying diseases is particularly important in the initial phase of chronic pruritus in order to prevent peripheral and central sensibilisation processes and thus chronification. Only after all this has been clarified can an individual therapy plan be drawn up. In addition, the skin lesions caused by scratching must be treated. In some cases an inpatient admission is also prescribed.

• #5

  https://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/dermatology/pruritus-itch/

  Pruritus or itch is defined as an unpleasant sensation of the skin that provokes the urge to scratch. It is a characteristic feature of many skin diseases and an unusual sign of some systemic diseases. Pruritus may be localized or generalized and can occur as an acute or chronic condition. Itching lasting more than 6 weeks is termed chronic pruritus. Itching can be intractable and incapacitating, as well as a diagnostic and therapeutic challenge. […] A detailed history is the single most important step toward diagnosing the cause of itching. This should include information on the onset, extent (generalized vs. localized), severity, type of itch, aggravating and alleviating factors, diurnal and seasonal variations, bathing, occupation, hobbies, medication history and allergies, and past medical and surgical history.

• #6 Pruritus: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p55.html

  Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. […] In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. […] The differential diagnosis of pruritus is broad and includes acute and chronic (i.e., at least six weeks of symptoms) presentations. Primary and secondary skin lesions suggest dermatologic etiologies of pruritus.

• #7 Pruritus: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p55.html

  When primary or secondary skin lesions are identified, but the etiology is not apparent, diagnostic testing of lesions should be considered. Skin biopsy, scrapings, and cultures may provide additional diagnostic information. […] If an occult exposure or underlying etiology is not apparent on initial evaluation, physicians should consider other systemic causes by obtaining laboratory and imaging studies. Serologic testing should include a complete blood count with differential and iron studies because iron deficiency anemia is the most common cause of generalized pruritus in patients with underlying systemic disease. […] The physical examination should include a complete dermatologic assessment, particularly for diffuse and chronic pruritus. Inspection of finger webs, the anogenital region, nails, and the scalp is suggested. […] If systemic disease is suspected, examination for lymphadenopathy and hepatosplenomegaly and additional diagnostic testing should be performed.

• #8 A Diagnostic Approach to Pruritus | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0715/p195.html

  Pruritus can be a symptom of a distinct dermatologic condition or of an occult underlying systemic disease. Of the patients referred to a dermatologist for generalized pruritus with no apparent primary cutaneous cause, 14 to 24 percent have a systemic etiology. […] In the absence of a primary skin lesion, the review of systems should include evaluation for thyroid disorders, lymphoma, kidney and liver diseases, and diabetes mellitus. Initial evaluation for systemic disease includes complete blood count and measurement of thyroid-stimulating hormone, fasting glucose, alkaline phosphatase, bilirubin, creatinine, and blood urea nitrogen. […] If the diagnosis is unclear after the history and physical examination or if initial empiric treatment is ineffective, a limited laboratory evaluation should be performed, including complete blood count and measurement of thyroid-stimulating hormone, fasting glucose, alkaline phosphatase, bilirubin, creatinine, and blood urea nitrogen.

• #9 Pruritus: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p55.html

  When primary or secondary skin lesions are identified, but the etiology is not apparent, diagnostic testing of lesions should be considered. Skin biopsy, scrapings, and cultures may provide additional diagnostic information. […] If an occult exposure or underlying etiology is not apparent on initial evaluation, physicians should consider other systemic causes by obtaining laboratory and imaging studies. Serologic testing should include a complete blood count with differential and iron studies because iron deficiency anemia is the most common cause of generalized pruritus in patients with underlying systemic disease. […] The physical examination should include a complete dermatologic assessment, particularly for diffuse and chronic pruritus. Inspection of finger webs, the anogenital region, nails, and the scalp is suggested. […] If systemic disease is suspected, examination for lymphadenopathy and hepatosplenomegaly and additional diagnostic testing should be performed.

• #10 Pruritus: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p55.html

  When primary or secondary skin lesions are identified, but the etiology is not apparent, diagnostic testing of lesions should be considered. Skin biopsy, scrapings, and cultures may provide additional diagnostic information. […] If an occult exposure or underlying etiology is not apparent on initial evaluation, physicians should consider other systemic causes by obtaining laboratory and imaging studies. Serologic testing should include a complete blood count with differential and iron studies because iron deficiency anemia is the most common cause of generalized pruritus in patients with underlying systemic disease. […] The physical examination should include a complete dermatologic assessment, particularly for diffuse and chronic pruritus. Inspection of finger webs, the anogenital region, nails, and the scalp is suggested. […] If systemic disease is suspected, examination for lymphadenopathy and hepatosplenomegaly and additional diagnostic testing should be performed.

• #11 A Diagnostic Approach to Pruritus | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0715/p195.html

  Pruritus can be a symptom of a distinct dermatologic condition or of an occult underlying systemic disease. Of the patients referred to a dermatologist for generalized pruritus with no apparent primary cutaneous cause, 14 to 24 percent have a systemic etiology. […] In the absence of a primary skin lesion, the review of systems should include evaluation for thyroid disorders, lymphoma, kidney and liver diseases, and diabetes mellitus. Initial evaluation for systemic disease includes complete blood count and measurement of thyroid-stimulating hormone, fasting glucose, alkaline phosphatase, bilirubin, creatinine, and blood urea nitrogen. […] If the diagnosis is unclear after the history and physical examination or if initial empiric treatment is ineffective, a limited laboratory evaluation should be performed, including complete blood count and measurement of thyroid-stimulating hormone, fasting glucose, alkaline phosphatase, bilirubin, creatinine, and blood urea nitrogen.

• #12 Pruritus: Diagnosis and Management – PubMed

  https://pubmed.ncbi.nlm.nih.gov/35029946/

  Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. Additional testing, including erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography, may also be appropriate based on the history and physical examination. […] In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. If the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist.

• #13 Pruritus: Diagnosis and Management – PubMed

  https://pubmed.ncbi.nlm.nih.gov/35029946/

  Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. Additional testing, including erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography, may also be appropriate based on the history and physical examination. […] In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. If the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist.

• #14 Pruritus (itch) – without a rash

  https://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

  Up to 50% of patients will have no clear cause for their itch and can be termed as having idiopathic pruritus, a diagnosis of exclusion. […] All patients with generalised pruritus who do not have an obvious dermatological cause for their itch require the following: Standard screen – FBC and ferritin, CRP, routine biochemistry, antimitochondrial antibody, urinalysis, a CXR to help exclude lymphoma and bronchial carcinoma, and a baseline LDH. […] In general, healthy patients with normal screening blood tests do not require detailed investigations to look for internal malignancy, however, the following groups of patients will require further investigations. […] Treat any underlying cause. If no cause is found and the symptoms remain moderate-severe / recalcitrant then remain vigilant to the possibility of a late presenting paraneoplastic condition, especially lymphoma.

• #15 Itchy skin (pruritus) – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/itchy-skin/diagnosis-treatment/drc-20355010

  Diagnosing the cause of itchy skin starts with a physical exam and questions about your medical history. If your health care provider thinks your itchy skin is the result of a medical condition, you might have tests, including: […] A complete blood count can provide evidence of an internal condition causing your itch, such as anemia. […] Liver or kidney disorders and thyroid conditions, such as hyperthyroidism, can cause itching. […] A chest X-ray can show if you have enlarged lymph nodes, which can go along with itchy skin. […] Your health care provider is likely to begin with your medical history and to ask you some questions, such as: When did you begin experiencing symptoms? […] Are tests needed to confirm the diagnosis? […] What are other possible causes for my symptoms? […] What is the best course of action?

• #16 Pruritus: Diagnosis and Management – PubMed

  https://pubmed.ncbi.nlm.nih.gov/35029946/

  Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. Additional testing, including erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography, may also be appropriate based on the history and physical examination. […] In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. If the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist.

• #17 Pruritus (itch) – without a rash

  https://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

  Up to 50% of patients will have no clear cause for their itch and can be termed as having idiopathic pruritus, a diagnosis of exclusion. […] All patients with generalised pruritus who do not have an obvious dermatological cause for their itch require the following: Standard screen – FBC and ferritin, CRP, routine biochemistry, antimitochondrial antibody, urinalysis, a CXR to help exclude lymphoma and bronchial carcinoma, and a baseline LDH. […] In general, healthy patients with normal screening blood tests do not require detailed investigations to look for internal malignancy, however, the following groups of patients will require further investigations. […] Treat any underlying cause. If no cause is found and the symptoms remain moderate-severe / recalcitrant then remain vigilant to the possibility of a late presenting paraneoplastic condition, especially lymphoma.

• #18 Diagnosis

  https://www.itchforum.net/for-patients/diagnosis/

  A number of itchy skin conditions can easily be diagnosed. However, it becomes more difficult with pruritus, which occurs in apparently normal skin or secondary lesions caused by scratching as a result of systemic diseases. If the pruritus does not stop at all, then the cause must be examined more closely. A detailed medical diagnosis, in which the skin and the internal organs are examined thoroughly, is then important. It is also important for the doctor to know when the pruritus began, whether there were any illnesses in the past and which medication was or is being taken. Also quality, intensity and frequency of pruritus are factors that play a role in the diagnosis. As pruritus is subjective and cannot be measured objectively, the symptom is often assessed via a questionnaire that you as a patient fill out. An individual and detailed anamnesis, clinical examination as well as interdisciplinary, laboratory chemical and radiological diagnostics are of great importance in the assessment of chronic pruritus. The clinical examination includes a complete inspection of the entire skin, including mucous membranes, scalp, hair, nails, and anogenital region. An X-ray image of the thorax and a sonography of the abdomen can provide indications of a possible malignant disease. In addition, the integration of other specialist disciplines (neurology, psychiatry, general medicine, allergology, dermatology, internal medicine [gastroenterology, hepatology, endocrinology, haematooncology], urology, gynaecology, etc.) plays an important role in diagnosis finding. The identification and treatment of underlying diseases is particularly important in the initial phase of chronic pruritus in order to prevent peripheral and central sensibilisation processes and thus chronification. Only after all this has been clarified can an individual therapy plan be drawn up. In addition, the skin lesions caused by scratching must be treated. In some cases an inpatient admission is also prescribed.

• #19 Pruritus: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p55.html

  When primary or secondary skin lesions are identified, but the etiology is not apparent, diagnostic testing of lesions should be considered. Skin biopsy, scrapings, and cultures may provide additional diagnostic information. […] If an occult exposure or underlying etiology is not apparent on initial evaluation, physicians should consider other systemic causes by obtaining laboratory and imaging studies. Serologic testing should include a complete blood count with differential and iron studies because iron deficiency anemia is the most common cause of generalized pruritus in patients with underlying systemic disease. […] The physical examination should include a complete dermatologic assessment, particularly for diffuse and chronic pruritus. Inspection of finger webs, the anogenital region, nails, and the scalp is suggested. […] If systemic disease is suspected, examination for lymphadenopathy and hepatosplenomegaly and additional diagnostic testing should be performed.

• #20

  https://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/dermatology/pruritus-itch/

  In some cases, the diagnosis is apparent from the history, physical examination, or bedside studies (such as a scabies preparation). When the diagnosis is not apparent, laboratory studies may be indicated. […] Histopathologic examination of the skin lesions may be required. In pruritus without a rash, a biopsy specimen for direct immunofluorescence from normal-appearing skin might show immune deposits in early cases of pemphigoid or findings diagnostic of mycosis fungoides in routine histopathology. […] Identifying and treating the underlying cause is the most effective therapy for pruritus. Symptomatic treatment should be prescribed while the primary condition is being treated.

• #21 Pruritus and Systemic Disease Workup: Laboratory Studies, Imaging Studies, Other Tests

  https://emedicine.medscape.com/article/1098029-workup

  When a primary dermatologic condition is excluded and a systemic cause is suspected, certain laboratory tests may aid diagnosis. […] If suspicion is low concerning a systemic disease, a 2-week trial of therapy with oilated soap for bathing, emollients for after the bath, and oral antihistamines may be attempted. If this fails, a laboratory evaluation is indicated. […] The following screening laboratory tests are recommended: […] Skin biopsy for routine pathology and immunofluorescence to exclude subacute occult autoimmune conditions such as pemphigoid and dermatitis herpetiformis. […] Negative findings from the initial evaluation do not necessarily exclude systemic disease, and follow-up screening may be repeated every 3-6 months if clinical suspicion continues. […] Skin biopsy for direct immunofluorescence and special stains may help exclude a primary dermatologic condition, such as dermatitis herpetiformis or bullous pemphigoid (ie, pruritic pemphigoid), or confirm a systemic cause, such as in mastocytosis.

• #22 Pruritus: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p55.html

  When primary or secondary skin lesions are identified, but the etiology is not apparent, diagnostic testing of lesions should be considered. Skin biopsy, scrapings, and cultures may provide additional diagnostic information. […] If an occult exposure or underlying etiology is not apparent on initial evaluation, physicians should consider other systemic causes by obtaining laboratory and imaging studies. Serologic testing should include a complete blood count with differential and iron studies because iron deficiency anemia is the most common cause of generalized pruritus in patients with underlying systemic disease. […] The physical examination should include a complete dermatologic assessment, particularly for diffuse and chronic pruritus. Inspection of finger webs, the anogenital region, nails, and the scalp is suggested. […] If systemic disease is suspected, examination for lymphadenopathy and hepatosplenomegaly and additional diagnostic testing should be performed.

• #23 Itch, pruritus

  https://dermnetnz.org/topics/pruritus

  Pruritus is the medical term for itch. Itch is an unpleasant sensation on the skin that provokes the desire to rub or scratch the area to obtain relief. Pruritus is often a symptom of an underlying disease process such as a skin problem, a systemic disease, or abnormal nerve impulses. […] The first steps of evaluation of an itchy patient are medical history and examination. A thorough history can identify constitutional symptoms that may point towards an underlying systemic disease. A careful examination can identify dermatological causes for the itch (eg scabies, lichen simplex, pemphigoid) or evidence of chronic skin changes related to the itch. Patients without primary skin lesions and little evidence of chronic scratching should be investigated for systemic, neuropathic and psychogenic causes.

• #24 Evaluation of pruritus – Differential diagnosis of symptoms | BMJ Best Practice US

  https://bestpractice.bmj.com/topics/en-us/612

  Pruritus is defined as an unpleasant sensation that causes a desire to scratch. The terms pruritus and itch are used synonymously. Pruritus is the most common subjective symptom in dermatology and may occur with or without visible skin lesions. It may be localized or generalized. […] It is important to distinguish between acute and chronic pruritus. Pruritus lasting 6 weeks is defined as chronic pruritus. Based on etiology, chronic pruritus may be classified as being of dermatologic, systemic, neurologic, psychogenic/psychosomatic, mixed, or unknown etiology. Chronic pruritus can be very distressing and refractory to treatment. Its intensity frequently correlates with degree of quality of life impairment, level of stigmatization, severity of depression, and emotional stress. […] According to the currently accepted clinical classification, patients with pruritus may be characterized as those with itching on primarily diseased, inflamed skin; pruritus on primarily normal, noninflamed skin; and itchy skin with chronic secondary scratch lesions.

• #25 Assessment of pruritus – Differential diagnosis of symptoms | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/612

  Pruritus is defined as an unpleasant sensation that causes a desire to scratch. The terms pruritus and itch are used synonymously. Pruritus is the most common subjective symptom in dermatology and may occur with or without visible skin lesions. It may be localised or generalised. […] It is important to distinguish between acute and chronic pruritus. Pruritus lasting 6 weeks is defined as chronic pruritus. Based on aetiology, chronic pruritus may be classified as being of dermatological, systemic, neurological, psychogenic/psychosomatic, mixed, or unknown aetiology. Chronic pruritus can be very distressing and refractory to treatment. Its intensity frequently correlates with degree of quality of life impairment, level of stigmatisation, severity of depression, and emotional stress. […] According to the currently accepted clinical classification, patients with pruritus may be characterised as those with itching on primarily diseased, inflamed skin; pruritus on primarily normal, non-inflamed skin; and itchy skin with chronic secondary scratch lesions.

• #26 Pruritus (Itchy Skin) Differential Diagnosis | Time of Care

  https://www.timeofcare.com/pruritus-differential-diagnosis/

  Dermatologic causes of pruritus include dry skin (xerosis), atopic dermatitis (eczema), allergic/irritant contact dermatitis, urticaria (hives), dermatophyte (tinea) infections, scabies, pediculosis (lice infestation), insect bites, folliculitis, lichen simplex chronicus, lichen planus, psoriasis, fungal infections, sunburn, polymorphous light eruption, pityriasis rosea, electrostatic charges, plaster of Paris casts, fiberglass and other irritants, photodermatitis, and bullous pemphigoid. […] Systemic causes of pruritus include pregnancy (third trimester), hepatobiliary causes such as cholestasis, primary biliary cirrhosis, cholestasis of pregnancy, oral contraceptives, extrahepatic biliary obstruction, chronic pancreatitis with obstruction of biliary tracts, hepatitis C, hepatitis (other than C), drug-induced cholestasis, sclerosing cholangitis, hematologic/hematopoietic disorders, endocrine and metabolic disorders, neoplastic conditions, autoimmune diseases, infectious diseases, neuropsychiatric conditions, and drug-related causes. […] It helps to divide the causes of pruritus into two major groups: dermatologic causes and systemic causes.

• #27 Differential diagnosis of very itchy skin

  https://dermnetnz.org/topics/differential-diagnosis-of-itchy-skin

  Itch is defined by a desire to scratch. […] An acute or chronic itchy rash is most often due to dermatitis/eczema. […] Dermatoscopic examination of hair shaft if scalp affected, possible burrows if hands affected. […] Swab for bacterial and viral culture if pustules, crusting. […] Skin biopsy for histopathology, and if available, direct immunofluorescence. […] If the itch is generalised and no primary skin rash observed, check blood count, iron studies, renal, liver and thyroid function, chest X-ray. […] General treatments for itchy skin conditions may include: Topical emollients, hydrocortisone cream, 1% menthol cream to cool localised itchy areas, oral antihistamines, tricyclic antidepressants such as amitriptyline. […] Is the itch localised or generalised? […] What is its distribution?

• #28 Evaluation of pruritus – Differential diagnosis of symptoms | BMJ Best Practice US

  https://bestpractice.bmj.com/topics/en-us/612

  Pruritus is a common symptom of many skin diseases. For example, it is a cardinal symptom of atopic eczema, and all patients with this disease are believed to have pruritus at some point during their illness. Similarly, about 70% to 90% of patients with psoriasis have pruritus. Pruritus may also complicate other systemic diseases, such as chronic renal failure, blood malignancies, or liver disorders. For instance, the frequency of chronic pruritus in hemodialysis patients has been estimated to be between 25% and 55%.

• #29 10 reasons your skin itches uncontrollably and how to get relief

  https://www.aad.org/public/everyday-care/itchy-skin/itch-relief/relieve-uncontrollably-itchy-skin

  Itchy skin condition. The list of skin conditions that can cause intense itch is long and includes: Atopic dermatitis, Chickenpox, Dyshidrotic eczema, Folliculitis, Hand-foot-and-mouth disease, Hives, Psoriasis, Neurodermatitis, Ringworm, Seborrheic dermatitis, Shingles. How to get relief: To get relief, you must know which skin condition you have. The best way to get an accurate diagnosis is to see a board-certified dermatologist. […] Skin cancer. For many people, the only sign of skin cancer is a new or changing spot on their skin. Sometimes, that spot also itches and can be the only reason a person notices the spot. How to get relief: See a board-certified dermatologist to find out if you have skin cancer. If you have skin cancer, treating it can get rid of the itch. […] Warning sign of a disease inside your body. Long-standing itch can be a sign of several diseases, including: Blood disease, Diabetes, Kidney disease, Liver disease, HIV, Overactive thyroid gland. Itch is common in people who have a disease that affects their blood, such as Hodgkins lymphoma or cutaneous T-cell lymphoma. It can also be a sign of advanced kidney disease and often develops in people who are close to needing dialysis or currently receiving dialysis. In these people, the itch can be widespread and especially intense on the back, arms, and legs. Itch is also common in people who have liver disease, such as hepatitis C, cirrhosis, or an obstructed bile duct. When itch is a sign of liver disease, the itch often starts on the palms and soles and spreads to other parts of the body. How to get relief: Getting an accurate diagnosis and treatment may relieve the itch. A dermatologist often plays a key role in diagnosing these diseases because itch can be the only symptom.

• #30 Pruritus: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p55.html

  When primary or secondary skin lesions are identified, but the etiology is not apparent, diagnostic testing of lesions should be considered. Skin biopsy, scrapings, and cultures may provide additional diagnostic information. […] If an occult exposure or underlying etiology is not apparent on initial evaluation, physicians should consider other systemic causes by obtaining laboratory and imaging studies. Serologic testing should include a complete blood count with differential and iron studies because iron deficiency anemia is the most common cause of generalized pruritus in patients with underlying systemic disease. […] The physical examination should include a complete dermatologic assessment, particularly for diffuse and chronic pruritus. Inspection of finger webs, the anogenital region, nails, and the scalp is suggested. […] If systemic disease is suspected, examination for lymphadenopathy and hepatosplenomegaly and additional diagnostic testing should be performed.

• #31 A Diagnostic Approach to Pruritus | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0715/p195.html

  Pruritus in the absence of a primary dermatologic etiology may be indicative of a serious underlying systemic disease. Studies have shown that 14 to 24 percent of patients presenting to a dermatologist’s office with pruritus and no primary dermatologic cause have a systemic condition. […] The possibility of an underlying malignant disease should be considered in patients with generalized pruritus of unknown cause. Among malignant diseases, Hodgkin lymphoma has the strongest association with pruritus, which occurs in up to 30 percent of patients with the disease.

• #32 Pruritus and Systemic Disease: Background, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/1098029-overview

  Pruritus is defined as an unpleasant sensation that provokes the desire to scratch. Certain systemic diseases have long been known to cause pruritus that ranges in intensity from a mild annoyance to an intractable, disabling condition. Generalized pruritus may be classified into the following categories on the basis of the underlying causative disease: renal pruritus, cholestatic pruritus, hematologic pruritus, endocrine pruritus, pruritus related to malignancy, and idiopathic generalized pruritus. […] However, when a primary skin condition cannot be identified as the cause of pruritus, then a systemic or neuropathic cause must be sought. Patients without signs of a primary skin condition should undergo a thorough evaluation of potential systemic causes of itching. […] Renal pruritus occurs in patients with CRF, most often those receiving HD. The exact cause is not known, although toxic substances retained during HD, histamine, opioids, and neural proliferation have been postulated as potential causes.

• #33 Pruritus and Systemic Disease: Background, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/1098029-overview

  Pruritus is defined as an unpleasant sensation that provokes the desire to scratch. Certain systemic diseases have long been known to cause pruritus that ranges in intensity from a mild annoyance to an intractable, disabling condition. Generalized pruritus may be classified into the following categories on the basis of the underlying causative disease: renal pruritus, cholestatic pruritus, hematologic pruritus, endocrine pruritus, pruritus related to malignancy, and idiopathic generalized pruritus. […] However, when a primary skin condition cannot be identified as the cause of pruritus, then a systemic or neuropathic cause must be sought. Patients without signs of a primary skin condition should undergo a thorough evaluation of potential systemic causes of itching. […] Renal pruritus occurs in patients with CRF, most often those receiving HD. The exact cause is not known, although toxic substances retained during HD, histamine, opioids, and neural proliferation have been postulated as potential causes.

• #34 Itchy skin (pruritus) – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/itchy-skin/symptoms-causes/syc-20355006

  Itchy skin is an irritating sensation that makes you want to scratch. It’s also called pruritus (proo-RIE-tus). […] Long-term relief requires identifying and treating the cause of itchy skin. […] See your health care provider or a skin disease specialist (dermatologist) if the itching: […] If the condition persists for three months despite treatment, see a dermatologist to be evaluated for skin disease. […] Causes of itchy skin include: […] Itching on the whole body might be a symptom of an underlying illness, such as liver disease, kidney disease, anemia, diabetes, thyroid problems and certain cancers. […] Itchy skin that is severe or lasts more than six weeks can affect the quality of your life. This type is called chronic pruritus.

• #35 What types of cancer can cause itchy skin? | MD Anderson Cancer Center

  https://www.mdanderson.org/cancerwise/what-types-of-cancer-can-cause-itchy-skin.h00-159774867.html

  Your skin can itch for many reasons, such as allergies, insect bites and dry skin. The itch, called pruritus, will usually go away once you treat whats causing it. But sometimes an itch can be chronic, meaning it lasts six weeks or longer. This is known as chronic pruritus. […] In rare cases, chronic pruritus can be a sign of cancer. […] Itching can be a sign of several types of blood cancers. […] Pruritus may be an associated symptom of cancer. That means it is often an additional symptom of the cancer itself. Its not necessarily a predictor of cancer. So, if you have itchy skin, it doesnt mean you will develop cancer. […] Sometimes, cancer treatment can cause rashes and itchy skin. Chemotherapy, opioids, aspirin and antibiotics may cause itching. […] Itchy skin can be frustrating, especially if you dont know whats causing it. Itching can be a sign of internal disease, including cancer. We know that patients with certain cancers, namely lymphomas and leukemias, often have associated pruritus, but we have limited data indicating that itchy skin is a predictor of cancer. So, itchy skin alone does not mean you will get cancer.

• #36 Pruritus: Diagnosis and Management – PubMed

  https://pubmed.ncbi.nlm.nih.gov/35029946/

  Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. Additional testing, including erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography, may also be appropriate based on the history and physical examination. […] In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. If the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist.

• #37 A Diagnostic Approach to Pruritus | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0715/p195.html

  Pruritus in the absence of a primary dermatologic etiology may be indicative of a serious underlying systemic disease. Studies have shown that 14 to 24 percent of patients presenting to a dermatologist’s office with pruritus and no primary dermatologic cause have a systemic condition. […] The possibility of an underlying malignant disease should be considered in patients with generalized pruritus of unknown cause. Among malignant diseases, Hodgkin lymphoma has the strongest association with pruritus, which occurs in up to 30 percent of patients with the disease.

• #38 Pruritus (itch) – without a rash

  https://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

  Generalised itch in the absence of any obvious dermatological condition is a very common problem with a prevalence of approximately 17% in adults and perhaps 50% or higher in the elderly. There are many causes and a logical approach is required to help formulate a diagnosis and management plan. […] Use a logical approach to try and ascertain a cause: […] The only way of knowing if the drug is responsible is by discontinuing the medication for a few weeks (if possible) and seeing if symptoms improve. […] Patients complain of an intense pricking itch on contact with water or change of skin temperature, but do not develop a rash. […] In the absence of signs of skin disease patients require a thorough history and an examination that should place special emphasis on examining for enlarged lymph nodes and hepatosplenomegaly.

• #39 Causes of itching | Coping with cancer | Cancer Research UK

  https://www.cancerresearchuk.org/about-cancer/coping/physically/skin-problems/dealing-with-itching/causes

  Itching is also called pruritus. […] It is important to talk to your healthcare team if you have itching. They can prescribe medicines to bring relief. […] You may need to have blood tests to check that your kidneys and liver are working normally. You may also have a test to check the number of different types of cells in your blood. Checking your levels of white blood cells called eosinophils can show whether an allergy is causing the itch. […] Itching can be a sign of an allergy. Talk to your doctor or nurse if you feel itchy after starting a new treatment. It may be that you need to change treatments. […] If you have an infection, you will need to have treatment for the type of infection you have. […] Some cancers cause itching. […] Doctors think it may be due to substances released by the tumour or by the body reacting to the tumour. […] Some cancer treatments cause itching. This may be itching over the whole body (generalised itching) or just in one part of the body. You may also have a rash. […] Find out whether itching is a side effect of your treatment.

• #40 Pruritus (Itchy Skin) Differential Diagnosis | Time of Care

  https://www.timeofcare.com/pruritus-differential-diagnosis/

  Dermatologic causes of pruritus include dry skin (xerosis), atopic dermatitis (eczema), allergic/irritant contact dermatitis, urticaria (hives), dermatophyte (tinea) infections, scabies, pediculosis (lice infestation), insect bites, folliculitis, lichen simplex chronicus, lichen planus, psoriasis, fungal infections, sunburn, polymorphous light eruption, pityriasis rosea, electrostatic charges, plaster of Paris casts, fiberglass and other irritants, photodermatitis, and bullous pemphigoid. […] Systemic causes of pruritus include pregnancy (third trimester), hepatobiliary causes such as cholestasis, primary biliary cirrhosis, cholestasis of pregnancy, oral contraceptives, extrahepatic biliary obstruction, chronic pancreatitis with obstruction of biliary tracts, hepatitis C, hepatitis (other than C), drug-induced cholestasis, sclerosing cholangitis, hematologic/hematopoietic disorders, endocrine and metabolic disorders, neoplastic conditions, autoimmune diseases, infectious diseases, neuropsychiatric conditions, and drug-related causes. […] It helps to divide the causes of pruritus into two major groups: dermatologic causes and systemic causes.

• #41 Itching and intrahepatic cholestasis of pregnancy – NHS

  https://www.nhs.uk/pregnancy/related-conditions/complications/itching-and-intrahepatic-cholestasis/

  ICP is diagnosed by excluding other causes of the itch. Your doctor will probably talk to you about your medical and family history and advise you to have some blood tests. […] These will include tests to check your liver function (LFT) and measure your bile acid levels (BA). […] If you are diagnosed with ICP, you will have regular liver blood tests (LFTs) and bile acid measurement tests so your doctor can monitor your condition. […] Initially, you may be given these tests every week. You may then be given more, or less, frequent tests depending on the results and your symptoms.

• #42 Pruritus diagnosis and treatment | Nursing in Practice

  https://www.nursinginpractice.com/clinical/pruritus-diagnosis-and-treatment/

  Pruritus diagnosis and treatment Sandra Lawton 30 Jul 2018 […] Pruritus that may be acute (less than six weeks) or chronic (more than six weeks) is classified as:1 […] Diagnosis of pruritus can be challenging, especially for chronic pruritus and requires a structured and systematic approach to identify the underlying cause for the pruritus.1,2 […] Consultations for chronic pruritus should include the following: […] Appropriate investigations, directed from the initial clinical assessment. […] The management of pruritus will be dependent on the underlying cause and diagnosis. […] Other interventions may include the use of behaviour modification including habit reversal training, phototherapy, the use of systemic medications, which include antidepressants such as tricyclic and SSRIs and anticonvulsants such as gabapentin and pregabalin.1 […] Although many treatment options are currently available, chronic pruritus remains a therapeutic challenge and often requires the use of combination therapies over a long period of time.

• #43 Algorithmic Approach: Diagnosis and Treatment of Pruritus in Dogs | Today’s Veterinary Practice

  https://todaysveterinarypractice.com/dermatology/pruritus-in-dogs/

  Pruritus (itch) in dogs is defined as an unpleasant sensation that provokes specific behaviors such as scratching, rubbing, and licking paws and is considered the most common clinical sign exhibited by dogs presented to veterinarians for skin disease. It can affect dogs’ quality of life and become a source of frustration for owners. […] A systematic diagnostic workup to identify the cause of pruritus is essential for appropriate treatment recommendations and clinical outcomes. The following algorithms provide further details on the diagnostic workup and treatment recommendations for pruritus in dogs. […] The first step in reaching an appropriate diagnosis and treatment recommendation is to look for ectoparasites by performing flea combing (for fleas and ticks) and skin scrapings (for mites).

• #44 Itch, pruritus

  https://dermnetnz.org/topics/pruritus

  Pruritus is the medical term for itch. Itch is an unpleasant sensation on the skin that provokes the desire to rub or scratch the area to obtain relief. Pruritus is often a symptom of an underlying disease process such as a skin problem, a systemic disease, or abnormal nerve impulses. […] The first steps of evaluation of an itchy patient are medical history and examination. A thorough history can identify constitutional symptoms that may point towards an underlying systemic disease. A careful examination can identify dermatological causes for the itch (eg scabies, lichen simplex, pemphigoid) or evidence of chronic skin changes related to the itch. Patients without primary skin lesions and little evidence of chronic scratching should be investigated for systemic, neuropathic and psychogenic causes.

• #45 Pruritus (itch) – without a rash

  https://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

  Generalised itch in the absence of any obvious dermatological condition is a very common problem with a prevalence of approximately 17% in adults and perhaps 50% or higher in the elderly. There are many causes and a logical approach is required to help formulate a diagnosis and management plan. […] Use a logical approach to try and ascertain a cause: […] The only way of knowing if the drug is responsible is by discontinuing the medication for a few weeks (if possible) and seeing if symptoms improve. […] Patients complain of an intense pricking itch on contact with water or change of skin temperature, but do not develop a rash. […] In the absence of signs of skin disease patients require a thorough history and an examination that should place special emphasis on examining for enlarged lymph nodes and hepatosplenomegaly.

• #46 Diagnosis and treatment of pruritus

  https://pmc.ncbi.nlm.nih.gov/articles/PMC5729138/

  Pruritus is the most common cutaneous symptom, yet it is difficult to diagnose and manage. […] The dominant causes of generalized itch are xerosis and eczema. Most patients will improve with nonpharmacologic therapy including frequent moisturization. […] A careful physical examination should be performed. Look for primary lesions. Chronic rubbing and scratching can result in nonspecific lesions that include lichenification, prurigo nodules, and excoriations. […] The foremost divide in the differential diagnosis is the distribution of pruritus—that is, whether the itch is localized or generalized. […] Unfortunately, pruritus is sometimes the cutaneous herald of more severe systemic disease. […] There is consensus that more extensive investigation should be reserved for patients who are both without physical findings of skin disease and unresponsive to a short course of antipruritic therapy.

• #47 A Diagnostic Approach to Pruritus | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0715/p195.html

  Pruritus can be a symptom of a distinct dermatologic condition or of an occult underlying systemic disease. Of the patients referred to a dermatologist for generalized pruritus with no apparent primary cutaneous cause, 14 to 24 percent have a systemic etiology. […] In the absence of a primary skin lesion, the review of systems should include evaluation for thyroid disorders, lymphoma, kidney and liver diseases, and diabetes mellitus. Initial evaluation for systemic disease includes complete blood count and measurement of thyroid-stimulating hormone, fasting glucose, alkaline phosphatase, bilirubin, creatinine, and blood urea nitrogen. […] If the diagnosis is unclear after the history and physical examination or if initial empiric treatment is ineffective, a limited laboratory evaluation should be performed, including complete blood count and measurement of thyroid-stimulating hormone, fasting glucose, alkaline phosphatase, bilirubin, creatinine, and blood urea nitrogen.

• #48 Pruritus (itch) – without a rash

  https://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

  Up to 50% of patients will have no clear cause for their itch and can be termed as having idiopathic pruritus, a diagnosis of exclusion. […] All patients with generalised pruritus who do not have an obvious dermatological cause for their itch require the following: Standard screen – FBC and ferritin, CRP, routine biochemistry, antimitochondrial antibody, urinalysis, a CXR to help exclude lymphoma and bronchial carcinoma, and a baseline LDH. […] In general, healthy patients with normal screening blood tests do not require detailed investigations to look for internal malignancy, however, the following groups of patients will require further investigations. […] Treat any underlying cause. If no cause is found and the symptoms remain moderate-severe / recalcitrant then remain vigilant to the possibility of a late presenting paraneoplastic condition, especially lymphoma.

• #49 Pruritus: Diagnosis and Management – PubMed

  https://pubmed.ncbi.nlm.nih.gov/35029946/

  Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. Additional testing, including erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography, may also be appropriate based on the history and physical examination. […] In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. If the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist.

• #50 Pruritus: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p55.html

  When primary or secondary skin lesions are identified, but the etiology is not apparent, diagnostic testing of lesions should be considered. Skin biopsy, scrapings, and cultures may provide additional diagnostic information. […] If an occult exposure or underlying etiology is not apparent on initial evaluation, physicians should consider other systemic causes by obtaining laboratory and imaging studies. Serologic testing should include a complete blood count with differential and iron studies because iron deficiency anemia is the most common cause of generalized pruritus in patients with underlying systemic disease. […] The physical examination should include a complete dermatologic assessment, particularly for diffuse and chronic pruritus. Inspection of finger webs, the anogenital region, nails, and the scalp is suggested. […] If systemic disease is suspected, examination for lymphadenopathy and hepatosplenomegaly and additional diagnostic testing should be performed.

• #51 Pruritus (itch) – without a rash

  https://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

  Up to 50% of patients will have no clear cause for their itch and can be termed as having idiopathic pruritus, a diagnosis of exclusion. […] All patients with generalised pruritus who do not have an obvious dermatological cause for their itch require the following: Standard screen – FBC and ferritin, CRP, routine biochemistry, antimitochondrial antibody, urinalysis, a CXR to help exclude lymphoma and bronchial carcinoma, and a baseline LDH. […] In general, healthy patients with normal screening blood tests do not require detailed investigations to look for internal malignancy, however, the following groups of patients will require further investigations. […] Treat any underlying cause. If no cause is found and the symptoms remain moderate-severe / recalcitrant then remain vigilant to the possibility of a late presenting paraneoplastic condition, especially lymphoma.

• #52 Pruritus and Systemic Disease Workup: Laboratory Studies, Imaging Studies, Other Tests

  https://emedicine.medscape.com/article/1098029-workup

  When a primary dermatologic condition is excluded and a systemic cause is suspected, certain laboratory tests may aid diagnosis. […] If suspicion is low concerning a systemic disease, a 2-week trial of therapy with oilated soap for bathing, emollients for after the bath, and oral antihistamines may be attempted. If this fails, a laboratory evaluation is indicated. […] The following screening laboratory tests are recommended: […] Skin biopsy for routine pathology and immunofluorescence to exclude subacute occult autoimmune conditions such as pemphigoid and dermatitis herpetiformis. […] Negative findings from the initial evaluation do not necessarily exclude systemic disease, and follow-up screening may be repeated every 3-6 months if clinical suspicion continues. […] Skin biopsy for direct immunofluorescence and special stains may help exclude a primary dermatologic condition, such as dermatitis herpetiformis or bullous pemphigoid (ie, pruritic pemphigoid), or confirm a systemic cause, such as in mastocytosis.

• #53 Pruritus: Diagnosis and Management – PubMed

  https://pubmed.ncbi.nlm.nih.gov/35029946/

  Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. Additional testing, including erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography, may also be appropriate based on the history and physical examination. […] In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. If the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist.

• #54 Diagnosis

  https://www.itchforum.net/for-patients/diagnosis/

  A number of itchy skin conditions can easily be diagnosed. However, it becomes more difficult with pruritus, which occurs in apparently normal skin or secondary lesions caused by scratching as a result of systemic diseases. If the pruritus does not stop at all, then the cause must be examined more closely. A detailed medical diagnosis, in which the skin and the internal organs are examined thoroughly, is then important. It is also important for the doctor to know when the pruritus began, whether there were any illnesses in the past and which medication was or is being taken. Also quality, intensity and frequency of pruritus are factors that play a role in the diagnosis. As pruritus is subjective and cannot be measured objectively, the symptom is often assessed via a questionnaire that you as a patient fill out. An individual and detailed anamnesis, clinical examination as well as interdisciplinary, laboratory chemical and radiological diagnostics are of great importance in the assessment of chronic pruritus. The clinical examination includes a complete inspection of the entire skin, including mucous membranes, scalp, hair, nails, and anogenital region. An X-ray image of the thorax and a sonography of the abdomen can provide indications of a possible malignant disease. In addition, the integration of other specialist disciplines (neurology, psychiatry, general medicine, allergology, dermatology, internal medicine [gastroenterology, hepatology, endocrinology, haematooncology], urology, gynaecology, etc.) plays an important role in diagnosis finding. The identification and treatment of underlying diseases is particularly important in the initial phase of chronic pruritus in order to prevent peripheral and central sensibilisation processes and thus chronification. Only after all this has been clarified can an individual therapy plan be drawn up. In addition, the skin lesions caused by scratching must be treated. In some cases an inpatient admission is also prescribed.

• #55 Pruritus: Diagnosis and Management – PubMed

  https://pubmed.ncbi.nlm.nih.gov/35029946/

  Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. Additional testing, including erythrocyte sedimentation rate, HIV screening, hepatitis serologies, and chest radiography, may also be appropriate based on the history and physical examination. […] In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. If the evaluation for multiple etiologies of pruritus is ambiguous, clinicians may consider psychogenic etiologies and consultation with a specialist.

• #56 Diagnosis

  https://www.itchforum.net/for-patients/diagnosis/

  A number of itchy skin conditions can easily be diagnosed. However, it becomes more difficult with pruritus, which occurs in apparently normal skin or secondary lesions caused by scratching as a result of systemic diseases. If the pruritus does not stop at all, then the cause must be examined more closely. A detailed medical diagnosis, in which the skin and the internal organs are examined thoroughly, is then important. It is also important for the doctor to know when the pruritus began, whether there were any illnesses in the past and which medication was or is being taken. Also quality, intensity and frequency of pruritus are factors that play a role in the diagnosis. As pruritus is subjective and cannot be measured objectively, the symptom is often assessed via a questionnaire that you as a patient fill out. An individual and detailed anamnesis, clinical examination as well as interdisciplinary, laboratory chemical and radiological diagnostics are of great importance in the assessment of chronic pruritus. The clinical examination includes a complete inspection of the entire skin, including mucous membranes, scalp, hair, nails, and anogenital region. An X-ray image of the thorax and a sonography of the abdomen can provide indications of a possible malignant disease. In addition, the integration of other specialist disciplines (neurology, psychiatry, general medicine, allergology, dermatology, internal medicine [gastroenterology, hepatology, endocrinology, haematooncology], urology, gynaecology, etc.) plays an important role in diagnosis finding. The identification and treatment of underlying diseases is particularly important in the initial phase of chronic pruritus in order to prevent peripheral and central sensibilisation processes and thus chronification. Only after all this has been clarified can an individual therapy plan be drawn up. In addition, the skin lesions caused by scratching must be treated. In some cases an inpatient admission is also prescribed.

• #57 Senile pruritus – Wikipedia

  https://en.wikipedia.org/wiki/Senile_pruritus

  Senile pruritus is one of the most common conditions in the elderly or people over 65 years of age with an emerging itch that may be accompanied with changes in temperature and textural characteristics. […] Diagnosis is based on an elimination criteria during a full body examination that can be done by either a dermatologist or non-dermatologist physician. […] Typically, senile pruritus is diagnosed following an exclusion process starting with a complete physical exam. If a person is exhibiting signs and symptoms of senile pruritus, a laboratory exam may not be recommended by a doctor at the initial doctor’s visit unless there are other indicators of an underlying disease. After being treated for xerosis and tested for scabies, if the senile pruritus persists, screening for an underlying systemic disease can be recommended. […] There are challenges that come with approaching treatment for senile pruritus because of the number of potential underlying causes physicians have to narrow down along with potential intolerances to certain therapies with people ages 65 or older.

• #58 Pruritus in the elderly – a guide to assessment and management

  https://www.racgp.org.au/afp/2014/october/pruritus-in-the-elderly-a-guide-to-assessment-and

  Pruritus in the elderly population remains both a diagnostic and therapeutic challenge. […] When a rash is present it could suggest an underlying primary dermatosis. […] Pruritus can be a manifestation of an underlying dermatological condition or part of an underlying systemic disease. […] The most common cause of itchy skin in the elderly, especially in autumn and winter is xerosis or dry skin. […] Examination should also look for possible secondary causes. […] It is reasonable to order a full blood count, renal, liver, fasting glucose and thyroid function studies in the first instance. […] A biopsy in the absence of any visible skin disease is unlikely to be helpful. […] Management can range from lifestyle modifications to specific medications. […] Regular use of emollients is the mainstay of treatment in pruritus, aiming to ensure optimal skin hydration and preventing the itch-scratch cycle. […] For patients with predominant urticarial symptoms a trial of antihistamines may be worthwhile. […] Topical corticosteroids can prove effective in managing pruritus, especially when related to an underlying inflammatory or immunological condition.

• #59 Pruritus in the elderly – a guide to assessment and management

  https://www.racgp.org.au/afp/2014/october/pruritus-in-the-elderly-a-guide-to-assessment-and

  Pruritus in the elderly population remains both a diagnostic and therapeutic challenge. […] When a rash is present it could suggest an underlying primary dermatosis. […] Pruritus can be a manifestation of an underlying dermatological condition or part of an underlying systemic disease. […] The most common cause of itchy skin in the elderly, especially in autumn and winter is xerosis or dry skin. […] Examination should also look for possible secondary causes. […] It is reasonable to order a full blood count, renal, liver, fasting glucose and thyroid function studies in the first instance. […] A biopsy in the absence of any visible skin disease is unlikely to be helpful. […] Management can range from lifestyle modifications to specific medications. […] Regular use of emollients is the mainstay of treatment in pruritus, aiming to ensure optimal skin hydration and preventing the itch-scratch cycle. […] For patients with predominant urticarial symptoms a trial of antihistamines may be worthwhile. […] Topical corticosteroids can prove effective in managing pruritus, especially when related to an underlying inflammatory or immunological condition.

• #60 Pruritus: Etiology and patient evaluation – UpToDate

  https://www.uptodate.com/contents/pruritus-etiology-and-patient-evaluation

  Pruritus (itch) is a common symptom, rather than a specific disease entity, that occurs in a diverse range of skin diseases (table 1). Pruritus may also appear as a prominent feature of extracutaneous disorders, such as systemic, neurologic, and psychiatric diseases (table 2). […] The pathogenesis and etiology of pruritus, as well as the evaluation of the patient with pruritus, will be reviewed here. […] Pruritus is a common symptom that is experienced by all human beings at some point during the course of life. […] Age, sex, and other demographic factors may influence risk for pruritus. […] Pruritus is common in older adults. Dry skin (xerosis) is probably the most common cause of pruritus in this population; additional frequent causes for pruritus in older adults are neuropathic changes and immunosenescence (age-associated changes in the immune system). Pruritus in older adults may also result from causes of pruritus that also affect the general population, such as atopic dermatitis, other inflammatory skin diseases, scabies, and systemic diseases.

• #61 Senile pruritus – Wikipedia

  https://en.wikipedia.org/wiki/Senile_pruritus

  Senile pruritus is one of the most common conditions in the elderly or people over 65 years of age with an emerging itch that may be accompanied with changes in temperature and textural characteristics. […] Diagnosis is based on an elimination criteria during a full body examination that can be done by either a dermatologist or non-dermatologist physician. […] Typically, senile pruritus is diagnosed following an exclusion process starting with a complete physical exam. If a person is exhibiting signs and symptoms of senile pruritus, a laboratory exam may not be recommended by a doctor at the initial doctor’s visit unless there are other indicators of an underlying disease. After being treated for xerosis and tested for scabies, if the senile pruritus persists, screening for an underlying systemic disease can be recommended. […] There are challenges that come with approaching treatment for senile pruritus because of the number of potential underlying causes physicians have to narrow down along with potential intolerances to certain therapies with people ages 65 or older.

• #62 A Diagnostic Approach to Pruritus | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0715/p195.html

  Pruritus in the absence of a primary dermatologic etiology may be indicative of a serious underlying systemic disease. Studies have shown that 14 to 24 percent of patients presenting to a dermatologist’s office with pruritus and no primary dermatologic cause have a systemic condition. […] The possibility of an underlying malignant disease should be considered in patients with generalized pruritus of unknown cause. Among malignant diseases, Hodgkin lymphoma has the strongest association with pruritus, which occurs in up to 30 percent of patients with the disease.

• #63 Is Itching a Sign of Cancer? | Dana-Farber Cancer Institute

  https://blog.dana-farber.org/insight/2019/09/is-itching-a-sign-of-cancer/

  Itching is rarely a sign that a person has cancer. […] The good news is that itchy skin is typically not a sign of cancer. […] Most skin cancers don’t cause itching, but anyone with a prolonged, unexplainable itch should consult either their primary care physician or a dermatologist. […] An itchy mole is considered a warning sign for melanoma and should be examined by a dermatologist. […] Itching can be common in people with Hodgkin lymphoma as well as other lymphoid malignancies, such as chronic lymphocytic leukemia (CLL). […] It is important to remember that itchiness is not a criterion for lymphoma staging and does not indicate a more or less favorable diagnosis. […] While rare, itchiness can be associated with malignancies, says Crombie. […] PV is a form of blood cancer in which the bone marrow produces an abnormal amount of red blood cells. […] Certain gastrointestinal cancers cancers that affect the digestive system may also lead to itchiness. […] Some cancer treatments may lead to itching or rashes, which can occur both over the entire body or in isolated areas.

• #64 What types of cancer can cause itchy skin? | MD Anderson Cancer Center

  https://www.mdanderson.org/cancerwise/what-types-of-cancer-can-cause-itchy-skin.h00-159774867.html

  Your skin can itch for many reasons, such as allergies, insect bites and dry skin. The itch, called pruritus, will usually go away once you treat whats causing it. But sometimes an itch can be chronic, meaning it lasts six weeks or longer. This is known as chronic pruritus. […] In rare cases, chronic pruritus can be a sign of cancer. […] Itching can be a sign of several types of blood cancers. […] Pruritus may be an associated symptom of cancer. That means it is often an additional symptom of the cancer itself. Its not necessarily a predictor of cancer. So, if you have itchy skin, it doesnt mean you will develop cancer. […] Sometimes, cancer treatment can cause rashes and itchy skin. Chemotherapy, opioids, aspirin and antibiotics may cause itching. […] Itchy skin can be frustrating, especially if you dont know whats causing it. Itching can be a sign of internal disease, including cancer. We know that patients with certain cancers, namely lymphomas and leukemias, often have associated pruritus, but we have limited data indicating that itchy skin is a predictor of cancer. So, itchy skin alone does not mean you will get cancer.

• #65 Pruritus and Systemic Disease: Background, Pathophysiology, Etiology

  https://emedicine.medscape.com/article/1098029-overview

  The exact mechanism of cholestatic pruritus is not known. However, bile salts, histamine, opioids, and an unknown pruritogen from damaged hepatocytes are postulated as potential causes. […] Numerous reports have linked pruritus to almost every type of malignancy. Release of toxins and the immune system have been suggested to play roles in malignancy-related pruritus. […] The prognosis is dependent on the underlying systemic illness that is causing the pruritus.

• #66 Can itchy skin be a sign of leukaemia?

  https://www.leukaemiacare.org.uk/support-and-information/latest-from-leukaemia-care/blog/can-itchy-skin-be-a-sign-of-leukaemia/

  Itchy skin is a problem we are all familiar with. However, did you know that in very rare cases, itchy skin can be caused by a serious underlying condition such as leukaemia? […] According to our patient survey Living Well with Leukaemia, around 9% of people with leukaemia will experience itchy skin as a symptom prior to their diagnosis. […] Itching occurs alongside other symptoms of leukaemia. […] The exact reason people with leukaemia or lymphoma sometimes develop itchy skin is not conclusively proven and is up for debate in scientific literature. […] Itching is one of the most common symptoms of this disorder, experienced by approximately 40% of patients. […] A full examination by your GP is necessary to accurately determine the cause and rule out any serious underlying issues. […] It is unlikely that itchy skin will occur on its own as a symptom of leukaemia.

• #67 Pruritus (itch) – without a rash

  https://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

  Up to 50% of patients will have no clear cause for their itch and can be termed as having idiopathic pruritus, a diagnosis of exclusion. […] All patients with generalised pruritus who do not have an obvious dermatological cause for their itch require the following: Standard screen – FBC and ferritin, CRP, routine biochemistry, antimitochondrial antibody, urinalysis, a CXR to help exclude lymphoma and bronchial carcinoma, and a baseline LDH. […] In general, healthy patients with normal screening blood tests do not require detailed investigations to look for internal malignancy, however, the following groups of patients will require further investigations. […] Treat any underlying cause. If no cause is found and the symptoms remain moderate-severe / recalcitrant then remain vigilant to the possibility of a late presenting paraneoplastic condition, especially lymphoma.

• #68 Psychogenic itch | Translational Psychiatry

  https://www.nature.com/articles/s41398-018-0097-7

  Psychogenic itch can be defined as an itch disorder where itch is at the center of the symptomatology and where psychological factors play an evident role in the triggering, intensity, aggravation, or persistence of the pruritus. […] Because differential diagnosis is difficult, the frequency is poorly known. […] Psychogenic itch is a diagnosis that is (too) frequently proposed by physicians, but patients diagnosed with psychogenic itch are (too) rarely referred to psychiatrists. […] The only epidemiological study of psychogenic itch reported that 6.5% of outpatients from a university department of dermatology suffered from somatoform pruritus. […] At the individual level, patients need an adequate diagnosis. […] Consequently, it is crucial to use a precise definition for correct diagnosis and research.

• #69 Neuropathic itch: Definition, diagnosis, treatment, and outlook

  https://www.medicalnewstoday.com/articles/neuropathic-itch

  Doctors may have difficulty diagnosing neuropathic itch, as they may initially assume that the problem is skin related because skin conditions are a much more common cause of itching. […] However, a dermatologist can rule out any dermatological causes of itching. […] Doctors usually prescribe topical treatments to people who present with itching. They may suspect neuropathic itch when these treatments do not work. […] Doctors may perform a skin biopsy when the cause of persistent skin symptoms is unknown. If the cause of a persistent itch isn’t known, a skin biopsy can sometimes be part of the diagnostic process.

• #70 Psychogenic itch | Translational Psychiatry

  https://www.nature.com/articles/s41398-018-0097-7

  The FPDG proposed 10 diagnostic criteria (3 compulsory and 7 optional) in its definition. […] Hence, the diagnosis of FID is possible in the presence of the three compulsory criteria and at least three out of seven of the optional ones. […] The main differential diagnosis is discussed in patients who scratch themselves in the absence of itch, those for whom itch is not the main cause of the scratching, and those whose scratching is disproportionate to the intensity of the itch. […] In contrast, psychogenic pruritus is related to an illusion of pruritus, but this pruritus is felt by the patient and is the main complaint. […] The announcement of a diagnosis of psychogenic pruritus to a patient is not easy or anecdotal and should be made cautiously. […] There has been no clinical trial of treatments for psychogenic itch, and the course of the disease is poorly known.

• #71 She Was Scratching Her Arms Raw. Would Anything Stop This Itch? – The New York Times

  https://www.nytimes.com/2024/11/29/well/mind/itch-brachioradial-pruritus-diagnosis.html

  The 62-year-old woman shifted in her seat. […] Her doctor back home had no idea what caused the crazy itch or what more she might do about it. […] She saw four dermatologists during the trip. None had any idea of what was wrong or what she could do about it. […] He noted that the injuries were limited to the upper and outer regions of her forearms. „You need an M.R.I. of your cervical spine,” he said. „You have brachioradial pruritus.” […] Brachioradial pruritus is a neurogenic itch caused not by anything in the skin but by nerves sending out a kind of distress signal. […] The patient did get an M.R.I., and it did show some degenerative disease in the lower vertebrae in her neck. […] He told her: He’d seen it before. […] The question was whether other anti-inflammatory drugs would, too.

• #72 Diagnosis and treatment of pruritus

  https://pmc.ncbi.nlm.nih.gov/articles/PMC5729138/

  Whenever possible, treatment should be directed at the primary cause of itch. Nonpharmacologic, topical, and systemic therapies are available. […] Many patients will benefit from nonpharmacologic therapies including frequent moisturization, avoiding overbathing, behavioural therapy, and breaking the itch-scratch cycle. Various topical and systemic therapies are available that could help patients who do not benefit from nonpharmacologic measures.

• #73 Itch, pruritus

  https://dermnetnz.org/topics/pruritus

  The management of pruritus relies on establishing the cause and then either removing or treating the cause to prevent further itching. In many cases, tests are necessary to determine the cause; while these are in progress, treatment to provide symptomatic relief of pruritus may be given. […] The symptom may quickly disappear or persist for long periods of time.

• #74 Pruritus (itch) – without a rash

  https://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

  Up to 50% of patients will have no clear cause for their itch and can be termed as having idiopathic pruritus, a diagnosis of exclusion. […] All patients with generalised pruritus who do not have an obvious dermatological cause for their itch require the following: Standard screen – FBC and ferritin, CRP, routine biochemistry, antimitochondrial antibody, urinalysis, a CXR to help exclude lymphoma and bronchial carcinoma, and a baseline LDH. […] In general, healthy patients with normal screening blood tests do not require detailed investigations to look for internal malignancy, however, the following groups of patients will require further investigations. […] Treat any underlying cause. If no cause is found and the symptoms remain moderate-severe / recalcitrant then remain vigilant to the possibility of a late presenting paraneoplastic condition, especially lymphoma.

• #75 Pruritus (Chronic Itchy Skin): Causes and Treatments

  https://www.webmd.com/skin-problems-and-treatments/skin-conditions-pruritus

  Pruritus Diagnosis […] Finding the cause of the itching is the first step in treating pruritus. If you aren’t able to get relief, if you’re itching all over your body, or if you have other unusual symptoms, see your doctor. […] They’ll start by looking at your skin and asking you questions. They’ll want to know things such as how long you’ve had the itch, whether anything makes it better or worse, and whether you’re having any other symptoms. […] You may have tests, including blood and imaging tests. The doctor may do a biopsy, where they remove a small piece of skin and look at it under a microscope.

• #76 Assessment of pruritus – Differential diagnosis of symptoms | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/612

  Pruritus is defined as an unpleasant sensation that causes a desire to scratch. The terms pruritus and itch are used synonymously. Pruritus is the most common subjective symptom in dermatology and may occur with or without visible skin lesions. It may be localised or generalised. […] It is important to distinguish between acute and chronic pruritus. Pruritus lasting 6 weeks is defined as chronic pruritus. Based on aetiology, chronic pruritus may be classified as being of dermatological, systemic, neurological, psychogenic/psychosomatic, mixed, or unknown aetiology. Chronic pruritus can be very distressing and refractory to treatment. Its intensity frequently correlates with degree of quality of life impairment, level of stigmatisation, severity of depression, and emotional stress. […] According to the currently accepted clinical classification, patients with pruritus may be characterised as those with itching on primarily diseased, inflamed skin; pruritus on primarily normal, non-inflamed skin; and itchy skin with chronic secondary scratch lesions.

• #77 Itch, pruritus

  https://dermnetnz.org/topics/pruritus

  The management of pruritus relies on establishing the cause and then either removing or treating the cause to prevent further itching. In many cases, tests are necessary to determine the cause; while these are in progress, treatment to provide symptomatic relief of pruritus may be given. […] The symptom may quickly disappear or persist for long periods of time.

• #78 Pruritus: Diagnosis and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p55.html

  Pruritus is the sensation of itching; it can be caused by dermatologic and systemic conditions. A thorough skin examination, including visualization of the finger webs, anogenital region, nails, and scalp, is essential. An initial evaluation for systemic causes may include a complete blood count with differential, creatinine and blood urea nitrogen levels, liver function tests, iron studies, fasting glucose or A1C level, and a thyroid-stimulating hormone test. […] In the absence of primary skin lesions, physicians should consider evaluation for malignancy in older patients with chronic generalized pruritus. General management includes trigger avoidance, liberal emollient use, limiting water exposure, and administration of oral antihistamines and topical corticosteroids. […] The differential diagnosis of pruritus is broad and includes acute and chronic (i.e., at least six weeks of symptoms) presentations. Primary and secondary skin lesions suggest dermatologic etiologies of pruritus.

• #79 Pruritus (itch) – without a rash

  https://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

  Generalised itch in the absence of any obvious dermatological condition is a very common problem with a prevalence of approximately 17% in adults and perhaps 50% or higher in the elderly. There are many causes and a logical approach is required to help formulate a diagnosis and management plan. […] Use a logical approach to try and ascertain a cause: […] The only way of knowing if the drug is responsible is by discontinuing the medication for a few weeks (if possible) and seeing if symptoms improve. […] Patients complain of an intense pricking itch on contact with water or change of skin temperature, but do not develop a rash. […] In the absence of signs of skin disease patients require a thorough history and an examination that should place special emphasis on examining for enlarged lymph nodes and hepatosplenomegaly.

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