Senile pruritus

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Senile pruritus
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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. [1] [2] [3] In the elderly, xerosis, is the most common cause for an itch due to the degradation of the skin barrier over time. [4] However, the cause of senile pruritus is not clearly known. [5] Diagnosis is based on an elimination criteria during a full body examination that can be done by either a dermatologist or non-dermatologist physician. [3]

Contents

Classification

This type of itch is just one out of six different classifications. [4]

The IFSI (International Forum for the Study of Itch) created another classification process for pruritus in the senile population. [6] There are three groups within the classification, the first being those who have pruritus on diseased skin, the second being those who non-diseased skin with pruritus, and the third being those who have secondary skin scratch lesions. [6] The secondary scratch lesions can include abrasions, pimples, bumps, crusts and other lesions that can be caused by irritating the skin through pinching, rubbing or scratching which can cause scarring. [6] This most often appears in group two or group three patients. Patients that fall into category two and three often have pruritus associated with the classifications listed above. [6]

Risk factors

Risk factors of senile pruritus may include: [1]

Potential causes

An itch can be caused by various reasons. The cause of senile pruritus is not clearly known, this type of itch in elderly patients may be a result of other reasons, like: [7]

While identifying the cause of senile pruritus can be challenging, there are some correlations between classifications/diagnosis of senile pruritus and clinical manifestation. For cutaneous diseases, the diagnosis could be dry skin (with flare ups at dry climate), irritant and allergic contact dermatitis (skin lesions), seborrheic dermatitis (skin lesions), atopic dermatitis (scratching, allokinesis, stinging, burning), psoriasis (skin lesions), urticaria (welts/skin swelling). Sometimes senile pruritus can manifest without a primary rash and with the absence of xerosis. [4]

Systemic diseases can lead to a senile pruritus diagnosis. For example chronic kidney disease (generalized or localized pruritus), hepatobiliary diseases (generalized pruritus), thyroid disorders (urticaria), polycythemia vera (generalized pruritus), iron deficiency anemia  (skin lesions/scratching) and hodgkin’s lymphoma (the area where lymph nodes are affected) can all lead to clinical manifestations of pruritus. [4] Various drugs can also induce pruritus which can manifest with or without a skin rash and can happen immediately or even months after the drug has been used by the patient. Neurological disorders such as postherpetic neuralgia, brachioradial pruritus and notalgia paraesthetica can also lead to senile pruritus with burning, stinging, scratching and/or lesions. [4] Psychiatric disorders such as schizophrenia, somatoform disorders, dissociative disorders, hallucinations, and delusional parasitosis can cause severe lesions, burning, stinging, as well as sensations of bugs crawling on skin over the entire body. [4]

Pathophysiology

Common pathways for the development of senile pruritus may include:

Xerosis

In the elderly, xerosis, is the most common cause for an itch due to the degradation of the skin barrier over time. [4] The skin barrier is critical for protecting the body from external pathogens, maintaining body temperature as well as other homeostatic or baseline functions. Over time, as the skin ages, the permeability barrier function begins to decline leading to dry skin. Reduced structural protein levels, lipids, as well as other critical enzymes that contribute to a strong epidermal(skin) barrier as seen overtime when compared to young skin. [4] Skin surface pH changes can also lead to chronic itch. Many properties that are needed for a functional barrier must reside at a more acidic pH, however, aged skin tends to be accompanied with a basic increase in pH. Disruptions in the pH gradient not only induce itch signaling but contribute to the overall decline in barrier function. [8] These intrinsic alterations leads aged skin to be more at risk for irritant exposure. Ultimately, the vulnerable barrier increases the risk of developing pruritus and other skin diseases.

Neurological

Another cause of senile pruritus may include neurological changes in the body as it ages. An itch is triggered by both the peripheral and central nervous system in response through a complex circuit of neurons. Specifically, c fibres and Aδ fibres are responsible for the itch response which have been seen to be inhibited at higher rates in the elderly. [3] In addition to neurological inhibition, skin hydration can have an effect on the nervous system circuit. Skin moisture keeps the barrier function intact, but reductions can lead to a decrease in the itch threshold needed to be reached. [3]

Immune system

Immunosenescence occurs over time where the immune system undergoes changes that may impact both the innate and adaptive immune systems. [8] These alterations may lead to increased immunoreactivity to intrinsic and extrinsic stimuli that can cause the body to become more sensitive and reactive. This may result in the form of an itch when exposed to stimuli that the body was not reactive to in the past. The immune system is responsible for a myriad of activities to defend the body from foreign substances via various endogenous and exogenous pathways. Within the lymphatic system, the thymus gland produces T cells that aid the immune system to recognize and attack potential harmful stimuli. In the case for the aging population, the thymus gland undergoes physical and chemical conformational changes that reduce the organ's size and therefore impacting its function to produce T cells. [8] This impairment may lead to decreased Th2 cells responsible for anti-body response when encountering allergens, bacteria, toxins, and other irritants, which may lead to an increase in autoreactivity-causing senile pruritus. [9]

Signs and symptoms

Senile pruritus can be caused by dry skin and it is common for skin to become more dry with age. [1] The back, legs, arms, scalp, and genitalia are areas of the body that are commonly affected by senile pruritus. [3] According to a study, most of the people who experience pruritus daily have increased itching sensations and other associated symptoms during the night. Most studies reveal that senile pruritus is more common in men than women. [3]

Common symptoms of senile pruritus include: [3]

The relationship between senile pruritus and seasonal weather changes has been studied but the results have been inconsistent. Some studies reveal that senile pruritus is most prevalent during Winter and Fall seasons while in other studies this correlation was not found to be significant. [3]

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. [10]

Treatment

Treatment usually consists of common remedies for age-related xerosis. However, repeated diagnosis requires further evaluation, taking into account a person's laboratory measurements and medical conditions. [11] A medical history is typically taken describing the severity of the pruritus on a scale of 0-10 (no itchiness to unbearable itchiness) and the location. Medication use is also documented to narrow down the cause of the pruritus. There is no complete treatment to eradicate the chronic itch due to the uncertainty of the cause so treatment is more-so palliative management.

Pharmacological Treatments

Topical

Topical treatments may be used to reduce inflammation and the painful or itchy sensation or flare-ups locally at the site on the skin. Topical treatments are typically safe for the geriatric population. [12] [13]

Topical treatments may include:

Systemic

The medication benefits and risks of systemic treatments are reviewed for elderly people suffering with pruritus due to various reasons, like underlying conditions. [12]

Anti-histamines

First generation anti-histamines can be useful due to their sedating qualities in treating pruritus. Second generation anti-histamines are used to treat allergies and can help reduce the inflammation in treating pruritus. Compared to first generation anti-histamines, second generation anti-histamines are typically non-sedating. However, they may not be used in elderly people because of their anticholinergic effects, like constipation and dry mouth.

Some common anti-histamine medications may include:

Immunosuppressants

Immunosuppressants have seen use at low doses alongside systemic steroids and phototherapy for chronic symptoms of senile pruritus or dermatitis. Senile pruritus could have connections to the loss of tolerance for antigens on the skin that result from aging skin, which can potentially lead to other autoimmune disorders like bullous pemphigoid. [14]

Immunosuppressive medications may include:

  • methotrexate, immunosuppressant and agent used in chemotherapy
  • azathioprine, immunosuppressant used as treatment in various conditions, such as an anti-rejection medication in kidney transplant patients
  • mycophenolate, immunosuppressant agent used in conditions, such as organ transplants and autoimmune diseases
Neuroleptics

Anticonvulsants have also found use as a substitute for oral antihistamines to treat senile pruritus, and can be adjusted accordingly to individual needs and characteristics. [11]

Other

Antidepressants and Opioid agonists/antagonists are also drug classes that may help dampen the itch response in people with pruritus. [13] Opioid antagonists have shown to be effective in relieving pruritus as well due to their antagonizing effects on receptors within the central nervous system. Psychotropic agents work very similar to anti-histamines for those who cannot use the latter. [6]

Topical salicylic acids and cannabinoids have been used for pruritus as well, though their pathway is not clearly known and need more studies before this can be shown as a safe and viable treatment. [13]

Non-pharmacological Treatments

Removing or avoiding certain stimuli in the surroundings that could potentially induce or exacerbate the itch are shown to be effective. [13] This includes avoid wearing clothing such as wool, nylon, latex, and other synthetic materials. Bathing in warmer water can inhibit the itch sensory fibers. Non-invasive brain stimulation, often used to treat neuropsychiatric conditions, has shown to be successful in repressing the itch cycle. [15] The device works by sending electrical currents that can redirect how the signaling cascade is fired through the peripheral and central nervous systems.

Phototherapy

Phototherapy can be considered under the guidance of a dermatologist. UV light phototherapy has been used to treat various pruritic symptoms such as pruritus resulting from renal disease, eczema, or just of unknown origin. [11]

Cooling agents

Usually used for temporary symptom relief and may decrease the severity of the itchiness. Cooling agents work as emollient replacements as dry, aged skin tend to lack the skin's natural emollients. Cooling agents like urea-based formulations help attract water into the skin, restoring the skin's hydration status. [16] Using refrigerated topical products may also be an option for additive cooling effects.

Soak and smear approach

Bathing for 15 minutes in a warm bath followed by applying a mixture of a topical steroid and heavy moisturizer (Aquaphor, Eucerin, etc.) may improve the moisture retention of the skin and helps with symptom relief. [17] Wrapping can be done onto the wet skin to maintain effectiveness of the treatment.

Avoidances

Certain materials can promote further pruritus and can be avoided to minimizes itchiness or reaction, so it may be helpful to decrease contact with wool and synthetic material. Soap-free substitutes are available to avoid any soap-related irritations to the skin. Avoiding the overuse of heating in the winter. Having a humidifier can increase humidity and allowing skin to be less dry in the cold and dry seasons. Shorter fingernails can also help to minimize scratching and reducing chances of bacterial infection. [18]

Complications

Severe, untreated chronic itch can lead to other skin diseases and/or progress into further skin damage. If left untreated, the itching may become too intense causing people to scratch themselves as a behavioral coping mechanism. Recurrent scratching, especially over the same area can lead to skin thickening which may prevent some medications from effectively working to treat the chronic itch. Senile pruritus can have a significant impact on the quality of life. Elderly people with this condition may feel more anxious or stressed due to their physical disposition. The urge to itch may feel so severe that it could affect their ability to sleep.

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. [19] Even certain ongoing medication usage can have a link to pruritus triggering in the elderly, but current treatments should not be the only thing to be wary of. A lot of it has to do with features that come with the ageing process whether it be systemic, psychogenic, or cutaneous conditions. [6] Every treatment used with the elderly is managed with caution because of potential risks involved, such as higher toxicity compared to younger individuals since medications are metabolized differently. [3]

See also

Related Research Articles

<span class="mw-page-title-main">Scabies</span> Human disease

Scabies is a contagious skin infestation by the mite Sarcoptes scabiei. The most common symptoms are severe itchiness and a pimple-like rash. Occasionally, tiny burrows may appear on the skin. In a first-ever infection, the infected person usually develops symptoms within two to six weeks. During a second infection, symptoms may begin within 24 hours. These symptoms can be present across most of the body or just certain areas such as the wrists, between fingers, or along the waistline. The head may be affected, but this is typically only in young children. The itch is often worse at night. Scratching may cause skin breakdown and an additional bacterial infection in the skin.

<span class="mw-page-title-main">Dermatitis</span> Inflammation of the skin

Dermatitis is inflammation of the skin, typically characterized by itchiness, redness and a rash. In cases of short duration, there may be small blisters, while in long-term cases the skin may become thickened. The area of skin involved can vary from small to covering the entire body. Dermatitis is often called eczema, and the difference between those terms is not standardized.

<span class="mw-page-title-main">Lichen simplex chronicus</span> Human skin disorder

Lichen simplex chronicus (LSC) is thick leathery skin with exaggerated skin markings caused by sudden itching and excessive rubbing and scratching. It generally results in small bumps, patches, scratch marks and scale. It typically affects the neck, scalp, upper eyelids, ears, palms, soles, ankles, wrists, genital areas and bottom. It often develops gradually and the scratching becomes a habit.

<span class="mw-page-title-main">Itch</span> Sensation that causes desire or reflex to scratch

Itch is a sensation that causes the desire or reflex to scratch. Itches have resisted many attempts to be classified as any one type of sensory experience. Itches have many similarities to pain, and while both are unpleasant sensory experiences, their behavioral response patterns are different. Pain creates a withdrawal reflex, whereas itches leads to a scratch reflex.

<span class="mw-page-title-main">Contact dermatitis</span> Human disease

Contact dermatitis is a type of acute or chronic inflammation of the skin caused by exposure to chemical or physical agents. Symptoms of contact dermatitis can include itchy or dry skin, a red rash, bumps, blisters, or swelling. These rashes are not contagious or life-threatening, but can be very uncomfortable.

<span class="mw-page-title-main">Hives</span> Skin disease characterized by red, raised, and itchy bumps

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Antipruritics, abirritants, or anti-itch drugs, are medications that inhibit the itching often associated with sunburns, allergic reactions, eczema, psoriasis, chickenpox, fungal infections, insect bites and stings like those from mosquitoes, fleas, and mites, and contact dermatitis and urticaria caused by plants such as poison ivy or stinging nettle. It can also be caused by chronic kidney disease and related conditions.

<span class="mw-page-title-main">Pityriasis rosea</span> Skin disease

Pityriasis rosea is a type of skin rash. Classically, it begins with a single red and slightly scaly area known as a "herald patch". This is then followed, days to weeks later, by an eruption of many smaller scaly spots; pinkish with a red edge in people with light skin and greyish in darker skin. About 20% of cases show atypical deviations from this pattern. It usually lasts less than three months and goes away without treatment. Sometimes malaise or a fever may occur before the start of the rash or itchiness, but often there are few other symptoms.

<span class="mw-page-title-main">Keratosis pilaris</span> Skin condition characterized by small bumps caused by overproduction of keratin

Keratosis pilaris is a common, autosomal-dominant, genetic condition of the skin's hair follicles characterized by the appearance of possibly itchy, small, gooseflesh-like bumps, with varying degrees of reddening or inflammation. It most often appears on the outer sides of the upper arms, thighs, face, back, and buttocks; KP can also occur on the hands, and tops of legs, sides, or any body part except glabrous (hairless) skin. Often the lesions can appear on the face, which may be mistaken for acne or folliculitis.

<span class="mw-page-title-main">Nummular dermatitis</span> Medical condition

Nummular dermatitis is one of the many forms of dermatitis. It is characterized by round or oval-shaped itchy lesions. The name comes from the Latin word "nummus," which means "coin."

<span class="mw-page-title-main">Mycosis fungoides</span> Most common form of cutaneous T-cell lymphoma

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<span class="mw-page-title-main">Atopic dermatitis</span> Long-term form of skin inflammation

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<span class="mw-page-title-main">Prurigo nodularis</span> Medical condition

Prurigo nodularis (PN), also known as nodular prurigo, is a skin disease characterised by pruritic (itchy) nodules which usually appear on the arms or legs. Patients often present with multiple excoriated lesions caused by scratching. PN is also known as Hyde prurigo nodularis, Picker's nodules, atypical nodular form of neurodermatitis circumscripta, lichen corneus obtusus.

Pruritus ani is the irritation of the skin at the exit of the rectum, known as the anus, causing the desire to scratch. The intensity of anal itching increases from moisture, pressure, and rubbing caused by clothing and sitting. At worst, anal itching causes intolerable discomfort that often is accompanied by burning and soreness. It is estimated that up to 5% of the population of the United States experiences this type of discomfort daily.

<span class="mw-page-title-main">Notalgia paresthetica</span> Neuropathy causing itching between the shoulder blades

Notalgia paresthetica or Notalgia paraesthetica (NP) (also known as "Hereditary localized pruritus", "Posterior pigmented pruritic patch", and "subscapular pruritus") is a chronic sensory neuropathy. Notalgia paresthetica is a common localized itch, affecting mainly the area between the shoulder blades (especially the T2–T6 dermatomes) but occasionally with a more widespread distribution, involving the shoulders, back, and upper chest. The characteristic symptom is pruritus (itch or sensation that makes a person want to scratch) on the back, usually on the left hand side below the shoulder blade (mid to upper back). It is occasionally accompanied by pain, paresthesia (pins and needles), or hyperesthesia (unusual or pathologically increased sensitivity of the skin to sensory stimuli, such as pain, heat, cold, or touch), which results in a well circumscribed hyperpigmentation of a skin patch in the affected area.

Pruritic folliculitis of pregnancy is a skin condition that occurs in one in 3000 people, about 0.2% of cases, who are in their second to third trimester of pregnancy where the hair follicle becomes inflamed or infected, resulting in a pus filled bump. Some dermatologic conditions aside from pruritic folliculitis during pregnancy include "pruritic urticarial papules and plaques of pregnancy, atopic eruption of pregnancy, pemphigoid gestationis, intrahepatic cholestasis of pregnancy, and pustular psoriasis of pregnancy". This pruritic folliculitis of pregnancy differs from typical pruritic folliculitis; in pregnancy, it is characterized by sterile hair follicles becoming inflamed mainly involving the trunk, contrasting how typical pruritic folliculitis is mainly localized on "the upper back, shoulders, and chest." This condition was first observed after some pregnant individuals showed signs of folliculitis that were different than seen before. The inflammation was thought to be caused by hormonal imbalance, infection from bacteria, fungi, viruses or even an ingrown hair. However, there is no known definitive cause as of yet. These bumps usually begin on the belly and then spread to upper regions of the body as well as the thighs.

Psychogenic pruritus, also known as psychogenic itch or functional itch disorder is pruritus not associated with a dermatologic or systemic cause. More often than not, it is attributed to a psychiatric cause. Psychogenic pruritus is not the same as neuropathic itch though both are conditions which require more research. This condition is not explained well in DSM-V and is typically considered a diagnosis of exclusion. This condition is not well-studied and it is difficult to ascertain as it is seen by both dermatologists and psychiatrists. In order to provide some consensus to this condition, The French Psychodermatology Group have created diagnostic criteria for this condition.

Brachioradial pruritus is an intense itching sensation of the arm usually between the wrist and elbow of either or both arms. The itch can be so intense that affected individuals will scratch their own skin to a bleeding condition.

References

  1. 1 2 3 Chen S, Zhou F, Xiong Y (February 2022). "Prevalence and risk factors of senile pruritus: a systematic review and meta-analysis". BMJ Open. 12 (2): e051694. doi:10.1136/bmjopen-2021-051694. PMC   8883222 . PMID   35210338.
  2. ↑ Yalçin B, Tamer E, Toy GG, Oztaş P, Hayran M, Alli N (June 2006). "The prevalence of skin diseases in the elderly: analysis of 4099 geriatric patients". International Journal of Dermatology. 45 (6): 672–676. doi: 10.1111/j.1365-4632.2005.02607.x . PMID   16796625. S2CID   36578748.
  3. 1 2 3 4 5 6 7 8 9 Clerc CJ, Misery L (April 2017). "A Literature Review of Senile Pruritus: From Diagnosis to Treatment". Acta Dermato-Venereologica. 97 (4): 433–440. doi: 10.2340/00015555-2574 . PMID   27840888.
  4. 1 2 3 4 5 6 7 8 9 Chung BY, Um JY, Kim JC, Kang SY, Park CW, Kim HO (December 2020). "Pathophysiology and Treatment of Pruritus in Elderly". International Journal of Molecular Sciences. 22 (1): E174. doi: 10.3390/ijms22010174 . PMC   7795219 . PMID   33375325.
  5. ↑ Bolognia J, Jorizzo JL, Rapini RP, eds. (2008). Dermatology (2nd ed.). Mosby/Elsevier. ISBN   978-1-4160-2999-1. OCLC   212399895.
  6. 1 2 3 4 5 6 Reich A, Ständer S, Szepietowski JC (2011-01-01). "Pruritus in the elderly". Clinics in Dermatology. Geriatric Dermatology. 29 (1): 15–23. doi:10.1016/j.clindermatol.2010.07.002. PMID   21146727.
  7. ↑ Julian B (2022). "Pruritus: What Is It, Causes, Types, Treatment, and More".
  8. 1 2 3 Valdes-Rodriguez R, Stull C, Yosipovitch G (March 2015). "Chronic pruritus in the elderly: pathophysiology, diagnosis and management". Drugs & Aging. 32 (3): 201–215. doi:10.1007/s40266-015-0246-0. PMID   25693757. S2CID   26123959.
  9. ↑ "T Helper 2 Cell Overview - US". www.thermofisher.com. Retrieved 2022-07-28.
  10. ↑ Ward JR, Bernhard JD (April 2005). "Willan's itch and other causes of pruritus in the elderly". International Journal of Dermatology. 44 (4): 267–73. doi:10.1111/j.1365-4632.2004.02553.x. PMID   15811075. S2CID   21299072.
  11. 1 2 3 Berger TG, Shive M, Harper GM (December 2013). "Pruritus in the older patient: a clinical review". JAMA. 310 (22): 2443–2450. doi:10.1001/jama.2013.282023. PMID   24327039.
  12. 1 2 Cao T, Tey HL, Yosipovitch G (July 2018). "Chronic Pruritus in the Geriatric Population". Dermatologic Clinics. Pruritus. 36 (3): 199–211. doi:10.1016/j.det.2018.02.004. PMID   29929593. S2CID   49332088.
  13. 1 2 3 4 Patel T, Yosipovitch G (September 2010). "The management of chronic pruritus in the elderly". Skin Therapy Letter. 15 (8): 5–9. PMID   20844849.
  14. ↑ Schmidt T, Sitaru C, Amber K, Hertl M (August 2014). "BP180- and BP230-specific IgG autoantibodies in pruritic disorders of the elderly: a preclinical stage of bullous pemphigoid?". The British Journal of Dermatology. 171 (2): 212–219. doi:10.1111/bjd.12936. PMID   24601973. S2CID   35363092.
  15. ↑ Sanders KM, Akiyama T (2018). "The vicious cycle of itch and anxiety". Neuroscience and Biobehavioral Reviews. 87: 17–26. doi:10.1016/j.neubiorev.2018.01.009. PMC   5845794 . PMID   29374516.
  16. ↑ Lacarrubba F, Verzì AE, Dinotta F, Micali G (April 2021). "10% urea cream in senile xerosis: Clinical and instrumental evaluation". Journal of Cosmetic Dermatology. 20 (Suppl 1): 5–8. doi:10.1111/jocd.14093. PMC   8251990 . PMID   33934477.
  17. ↑ Berger TG, Steinhoff M (2011). "Pruritus in elderly patients--eruptions of senescence". Seminars in Cutaneous Medicine and Surgery. 30: 113–117. doi:10.1016/j.sder.2011.04.002. PMC   3694596 . PMID   21767773.
  18. ↑ The Royal Australian College of general Practitioners (2014). "Pruritus in the elderly – a guide to assessment and management". Australian Family Physician. Retrieved 2022-08-01.
  19. ↑ Pereira MP, Ständer S (2018). "Therapy for pruritus in the elderly: a review of treatment developments". Expert Opinion on Pharmacotherapy. 19: 443–450. doi:10.1080/14656566.2018.1444752. PMID   29493371. S2CID   3974627.
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