Responses and Reactions of Obriz M. Paglinawan
to
Dr. Joson's Comments and Inquiries

Topics:

Overview and Personal Perspective on Pruritus as a Health Problem

Hypothetical Patient Management on Pruritus

Overview and Personal Perspective on Pruritus as a Health Problem

a. Definition

RJ's Inquiries:

- How about layman concept of pruritus?

Obriz's Response and Reactions:

· The layman's term for pruritus is itch.

· Itch - is a local discomfort or an uneasy irritating sensation of the skin, prompting the sufferer to scratch or rub the affected area.

RJ's Inquiries:

- Can you have itchiness on the mucosa? Or is it confined to the skin only?

Obriz's Reactions:

· Yes, it can be possible such as pruritus in the cutaneous tissue or the vulva, anus, or body folds which are caused by mucocutaneous candidiasis.

· As we know from Dr. Kenneth H. Neldner that itch and pain sensations are believed to be transmitted by the same C fibers originating as free nerve nets at the dermal-epidermal junction and surrounding hair follicles. Through basically unknown physical-chemical mechanisms, minimal stimulation of these fibers is thought to cause pruritus or itchiness, whereas more intense stimulation of the same fibers causes pain. Hence, in the mucosa or the mucous membrane, which is the moist membrane lining many tubular structures and cavities, including the nasal sinuses, respiratory tract, gastrointestinal tract, biliary, and pancreatic systems as well as the surface of the mouth which consists of a surface layer of epithelium, which contains glands secreting mucus, with underlying layers of connective tissue (lamina propia) and muscularis mucosae, which forms the inner boundary of the mucous membrane, can also be affected due to the fact that there are also nerve endings there as well as pain sensations.

b. Effect

Obriz's Response and Reactions:

· Yes, it can affect the biopsychosocial well-being of an individual who experiences it.

· Yes, it can cause disability and to some extent, it can lead to death but death will ensue only due to the underlying cause for example a systemic cause that leads to pruritus, if not treated appropriately, it can lead to death. Yet, for a localized pruritus, it's not so serious that death will ensue but it can only affect the socioeconomic productivity of the individuals, families, and communities in the sense that they are not comfortable in status of having a pruritic skin.

II. Common types

Oriz's Response and Reactions:

· Yes, there is such thing as mucosal pruritus and even perhaps, mucosal pain per se. Thus, the classification will be pruritus on the skin either by generalized or localized and pruritus in mucosae.

III. Common Causes

RJ's Comments and Inquiries:

- Which ones are prone to cause generalized pruritus?

- Localized pruritus?

- Indicate as these may be helpful in clinical diagnosis.

Obriz's Response and Reactions:

· To cause a generalized pruritus are basically the systemic disorders.

· To cause a localized pruritus are basically the focal or the primary skin disorders such as: infections, chemicals, environmental, trauma, and the psychogenic disorders.

IV. Magnitude

RJ's Inquiries:

- Which ones are more common? Localized or generalized pruritus? Primary skin disorders or systemic disorders causing pruritus or psychogenic disorders causing pruritus?

Obriz's Response:

· The more common are the localized pruritus and in terms of its cause, the primary skin disorders ranks the most common, psychogenic next, and systemic disorders are the last.

· Contact and atopic dermatitis, eczema, and scabies are examples for primary skin disorders but for scabies, it can sometimes be generalized pruritus in its manifestation per se.

V. Personal Perspective

Obriz's Reactions:

· Yes, I am amenable with your idea that primary prevention is still the best strategy to prevent this skin problem.

· With regard to community programs, yes, I am also amenable with your suggestion that primary skin disorders should be given priority in terms of program design, implementation and evaluation. However, it should also be important to consider the systemic and psychogenic factors hence, these factors can also lead to pruritus.

Topic: Hypothetical Patient Management

RJ's Comments and Inquiries:

- So you think the more common causes are the primary skin disorders and systemic disorders followed by psychogenic disorders?

- What are the more common specific conditions?

Infestations, allergies, chemicals, etc.?

Obriz's Response and Reactions:

· As far as magnitude or prevalence is concerned, the more common causes of this problem are the primary skin disorders, next is the psychogenic disorders and last is the systemic disorders.

· The more common specific conditions are the following:

- Infections, Allergies, Chemicals, Environmental, Trauma, emotional stress, infestations such as: scabies, hookworm, Ascariasis.

Trigger II

Question #2

RJ's Comments and Inquiries:

- In my opinion, contact dermatitis is usually associated with localized pruritus. Thus, that should not be the primary consideration.

- Primary considerations will be primary skin disorders that produce generalized pruritic rashes. What produce generalized rashes? Infections and infestations? Viral exanthems can produce generalized rashes. Infestations such as those caused by generalized scabies can also produce generalized pruritic rashes. Because of the dry lichenified hyperpigmented scaly lesions on the extremities, signifying a chronic affair, scabies is more probable than viral exanthems, based on the available data. One would certainly need more data.

- In your table, you did not demonstrate differences between contact dermatitis and scabies. You did not show the basis for choosing contact dermatitis as your primary diagnosis.

Obriz's Response and Reactions:

· Thank you for your opinion. As regards to my primary diagnosis now, I will change it to Scabies and the secondary diagnosis will be Atopic Dermatitis.

· The basis for diagnosis for Scabies are the following:

- Generalized itching

- Pruritic vesicles and pustules in "runs" or "galleries," especially on the sides of the fingers and the heels of the palms and in wrist creases.

- Mites, ova, and brown dots of feces visible microscopically.

- Red papules or nodules on the penile glands and shaft are pathognomonic.

· The basis for diagnosis for atopic dermatitis are the following:

- Pruritic, exudative, or lichenified eruption on face, neck, upper trunk, wrists, and hands and in antecubital and popliteal folds.

- Personal or family history of allergic manifestations (e.g., asthma, allergic rhinitis, atopic dermatitis).

- Tendency to recur, with remission from adolescent to age 20.

Question # 3

RJ's Comments and Inquiries:

- As mentioned above, more data are needed to firm up initial suspicions of scabies vs viral exanthems.

- Core data needed will be onset or duration, characteristics of rashes, diffusely generalized or generalized but with concentration on some areas, specific type of rashes, where they started, any identifying precipitating factors, any associated signs and symptoms of systemic inflammation and infection that would suggest viral exanthem. Any previous medical consult?

- The data you supplied are not very helpful. You have to secure more data based on what I have pointed out in the previous paragraph.

- In the absence of informative data, I would still consider scabies and atopic dermatitis as the possible causes of chronic generalized rashes. Do atopic dermatitis or contact dermatitis produce generalized rashes? If they do, they should be considered.

- With a history of asthma and probably chronic rhinitis (possibly, allergic rhinitis), I would consider atopic dermatitis more than contact dermatitis as the primary diagnosis. Is atopic dermatitis the same as contact dermatitis? The secondary diagnosis could be scabies as this may be a cause of generalized pruritic rashes.

Obriz's Reactions:

· Additional data to firm up the Primary diagnosis which is now "SCABIES".

- Had previous consult and was given glucocorticoid a few months ago.

- (+) of a family member with scabies.

- Onset of symptoms occurs a few weeks only.

- Duration of itchiness lasts for 1 month already

- Itching is intense that worsens at night and after a hot shower.

- Lesions generally develop on the volar wrists, between the fingers, on the elbows, and on the penis.

- Small papules and vesicles, often accompanied by eczematous plaques, pustules, or nodules, are symmetrically distributed in these sites and in skin folds under the breasts and around the navel, axillae, belt line, buttocks, upper thighs, and scrotum.

· Atopic dermatitis is different from contact dermatitis hence atopic dermatitis is usually associated with atopic diseases, and not only a merely of allergic cause while contact dermatitis can be caused by allergens, chemicals, toxins and etc that are in contact with the skin resulting to allergic reactions to the skin and it's either by active or delayed type of reaction.

Question #4

RJ's Comments and Inquiries:

- YES, definitely. Since the data you gave are lacking and will not give a diagnosis with certainty.

- Don't use the availability of paraclinical diagnostic option as an excuse not to get symptom and sign data diligently.

Obriz's Reactions:

· Additional data are already given as stated above.

Question #5

RJ's Comments and Inquiries:

- You have to be more detailed than giving pluses. Spell out the differences.

- Considering that your primary diagnosis is contact dermatitis and your secondary diagnosis is scabies, in looking for paraclinical diagnostic options, focus your attention first on the primary diagnosis. Are there reliable paraclinical diagnostic procedures for contact dermatitis? If there are none, consider options for the secondary diagnosis.

- Is skin test a reliable diagnostic procedure for contact dermatitis? Burrow ink test is a test for scabies, right? CBC is definitely very nonspecific.

Obriz's Response and Reactions:

· These are the three options for a paraclinical diagnosis:

- Skin Biopsy (instead of CBC)

- Burrow ink Test

- Skin test (patch test)

- Skin Biopsy is very specific for scabies.

- Burrow ink test is also specific for scabies.

- Skin test can detect atopic dermatitis.

Note:

All of these diagnostic procedures are available yet, skin biopsy has a greater risk hence it involves invasive procedure while burrow ink test and skin test are not invasive.

With regard to its benefit, biopsy is more specific for scabies, likewise, burrow ink test can also detect the organism cause scabies while patch test is also very specific for atopic dermatitis.

However, biopsy is more costly compared to burrow ink test and patch test.

Question #6

RJ's Comments and Inquiries:

- Is atopic dermatitis and contact dermatitis the same?

- What will be a positive finding of atopic dermatitis or contact dermatitis on skin test?

Obriz's Reactions:

- Atopic dermatitis is different from contact dermatitis hence atopic dermatitis is usually associated with atopic diseases, and not only a merely of allergic cause while contact dermatitis can be caused by allergens, chemicals, toxins and etc that are in contact with the skin resulting to allergic reactions to the skin and it's either by active or delayed type of reaction.

· There was a positive delayed hypersensitivity which was manifested by swollen or reddened skin at the site of the patched skin after a given period of time.

Trigger 3

Question #1

RJ's Comments and Inquiries:

- How do you interpret the presence of delayed hypersensitivity?

- Is this diagnostic of atopic dermatitis?

- Answer the question directly.

Obriz's Reactions:

· Delayed hypersensitivity means a positive result for atopic dermatitis and that means the patient is allergic to some allergens being tested on him on the patch test.

· Yes, but sometimes it can yield a false-positive result thus blinded food challenges are the most reliable. RASTs or skin tests may suggest dust mite allergy.

Question #2

RJ's Comments and Inquiries:

- You did not answer the question "Why?" If the delayed hypersensitivity on skin test is a reliable diagnostic parameter of atopic dermatitis and since you are primarily considering atopic dermatitis, then you accept the skin test result as the diagnosis.

Obriz's Reactions:

· My primary diagnosis now is SCABIES while the secondary is ATOPIC DERMATITIS because basing from the additional data, the patient precisely depicts the characteristics manifestations for scabies.

Question #4

RJ's Comments and Inquiries:

- Is contact dermatitis the same as atopic dermatitis?

- You kept on changing the terminologies!

Obriz's Response and Reactions:

· Atopic dermatitis is different from contact dermatitis hence atopic dermatitis is usually associated with atopic diseases, and not only merely of allergic cause while contact dermatitis can be caused by allergens, chemicals, toxins and etc that are in contact with the skin resulting to allergic reactions to the skin and it's either by active or delayed type of reaction.

· I'm not changing my terminologies. It's just a clerical error. Well, anyway, as for my primary diagnosis now is SCABIES and the secondary diagnosis is ATOPIC DERMATITIS.

Question #6

RJ's Comments and Inquiries:

- What are the treatment options for atopic dermatitis?

- What are the definitive treatments? Steroids? Others?

- What are the treatments options for pruritus? Cold compresses?

- Wet dressing? Corticosteroids?

- Compare them in terms of benefit, risk, cost, availability!

Obriz's Response and Reactions:

· Treatment options for scabies and atopic dermatitis are the following:

· For Scabies:

- For the treatment of scabies, 5% permethrin cream is less toxic than the once commonly used 1% lindane preparations and is effective against lindane-tolerant infestations.

- Both scabicides are applied thinly but thoroughly behind the ears and from the neck down after bathing and are removed 8 h later with soap and water.

- Lindane is absorbed through the skin, and its overuse has led to seizures and aplastic anemia. It should not be applied to pregnant women or infants.

- Alternatives include topical crotamiton cream, benzyl benzoate, and sulfur ointments. Successful treatment of crusted scabies requires the application first of a keratolytic agent such as 6% salicylic acid (to improve the penetration of scabicides) and then of scabicides to the scalp, face, and ears (with care to avoid the eyes).

- Repeated treatments or the sequential use of several agents may be necessary. A single oral dose of ivermectin (200 ug/kg) effectively treats scabies in otherwise healthy persons. Patients with crusted scabies may require two or more doses of ivermectin.

- Although effectively treated scabies infestations become noninfectious within a day, itching and rash due to hypersensitivity frequently persist for weeks or months.

- Unnecessary pretreatment of the affected patients may provoke contact dermatitis.

- Antihistamines, salicylates, and calamine lotion relieve itching during treatment, and topical glucocorticoids are useful for the pruritus that lingers after effective treatment.

- An oral antibiotic may be necessary for bacterial superinfections that fail to resolve with antiscabietic therapy. To prevent reinfestations, bedding and clothing should be washed in hot water, and close contacts, even if asymptomatic, should be treated simultaneously.

- Wet dressings and cold compress are only applicable for contact dermatitis or for atopic dermatitis. They are applied in the area where pruritus is intense for at least 30-60 minutes.

- Corticosteroids as well as antibiotics per se are the mainstay of treatment for scabies as well as for atopic dermatitis. Corticosteroids are effective in the sense that it can suppress the histamine that triggers the pruritus manifestations. It can suppress the immune system thus there's a great susceptibility for infection. Adverse effects are the following: peptic ulceration, myopathy, psychological disturbances, posterior subcapsular cataracts, osteoporosis, hyperglycemia and suppression of pituitary -adrenal function.

- The benefits of using corticosteroids are great in such a way that it can really cure the manifestation while the risks also are great due to its avid side effects thus as physicians, we have to evaluate our patients whether the patients can really tolerate the side effects that corticosteroids will do.

· For Atopic Dermatitis:

- General Measures

- Atopic individuals are sensitive to low humidity and often get worse in the winter, when the air is dry. A reasonable approach is not to let children or adults bathe more than once daily, not to let children sit in soapy water, and not to permit use of bubble bath unless it is shown not to irritate the skin of that child.

- Soap should be confined to the armpits, groin, and feet and should be used only just before rinsing and ending the bath. Wash cloths and brushes should not be used. Soaps should not be drying, and Dove, Eucerin, Aveeno, Basis, Alpha Keri, Purpose, and other soaps or cleansers, such as Cetaphil or Aquanil, may be recommended. After rinsing, the skin should be patted dry (not rubbed) and then immediately before it dries completely - covered with a thin film of an emollient, such as Aquaphor, Eucerin, Dermasil, DML Cream, Vaseline, mineral oil, or a corticosteroid as needed.

- To determine the potential effect of foods, the parent may eliminate one food at a time that is thought to induce flares. Dairy products and wheat are the most common offenders. Foods that are a problem typically cause itching within minutes to a few hours.

- Therapy of atopic dermatitis should be based on avoidance of cutaneous irritants, adequate cutaneous hydration, judicious use of low- or midpotency topical glucocorticoids, and prompt treatment of secondarily infected skin lesions. Patients should be instructed to bathe using warm, but not hot, water and to limit their use of soap. Immediately after bathing, the skin should be lubricated with a low- or midpotency topical glucocorticoid in a cream or ointment base. Crusted and weeping skin lesions should be treated with systemic antibiotics with activity against Staph. aureus, since secondary infection often exacerbates eczema. The role of dietary allergens in atopic dermatitis is controversial, but there is little evidence that they play any role outside of infancy.

- Local Treatment

- Corticosteroids in lotion, cream, or ointment form have almost completely supplanted other topical medications but should not be the only therapy in severe disease. They should be applied sparingly twice to four times daily and rubbed in well. Their potency should be appropriate to the severity of the dermatitis.

- In general, one should begin with hydrocortisone or another slightly stronger mild steroid (Aclovate, Desonide) and use triamcinolone 0.1% for short periods of time as needed in young children. It is vital that patients taper corticosteroids and substitute emollients when the dermatitis clears to avoid both tachyphylaxis and the side effects of corticosteroids.

- Tapering is also important to avoid rebound flares of the dermatitis that may follow their abrupt cessation. Doxepin cream 5% has been approved for treatment of pruritus in atopic dermatitis and is used four times daily.

- It is best applied simultaneously with the topical steroid. Stinging, burning, and drowsiness were reported in 25%.

- Systemic and Adjuvant Therapy

- Treatment with systemic glucocorticoids should be limited to severe exacerbations unresponsive to conservative topical therapy. In the patient with chronic atopic eczema, therapy with systemic glucocorticoids will generally clear the skin only briefly, but cessation of the systemic therapy will invariably be accompanied by return, if not worsening, of the dermatitis. Patients who do not respond to conventional therapies should be considered for patch testing to rule out allergic contact dermatitis. In rare instances, severe unremitting atopic dermatitis may require systemic immunosuppressive therapy, but this should be used with extreme caution.

- Oral prednisone dosages should be high enough to suppress the dermatitis quickly, usually starting with 40-60 mg daily for adults. The dosage is then tapered to nil over a period of 2-4 weeks.

- Triamcinolone acetonide suspension, 40-60 mg intramuscularly for adults, used occasionally - but not more frequently than every 4-6 weeks - may exert control but is not a good form of maintenance therapy. Classic antihistamines may be used to aid in th4e relief of severe pruritus.

- Hydroxyzine, brompheniramine, or doxepin may be useful, but the dosage must be increased gradually to avoid drowsiness.

- Fissures, crusts, erosions, pustules indicate staphylococcal infection clinically. Therefore, antistaphylococcal antibiotics given systemically - such as dicloxacillin or first-generation cephalosporins - may be helpful in management and are often used during flares.

- Phototherapy can be an important adjunct for severely affected patients, and the properly selected patient with recalcitrant disease may benefit greatly from therapy with UVB, UVB and UVA with or without coal tar, or PUVA.

Prepared by:
Dr. Obriz M. Paglinawan
SWU-MHAM, PBL-III Student
September, 1999
obrizpeace@eudoramail.com

Obriz M. Paglinawan's Paper (with RJ's Comments and Inquiries) on

Overview and Personal Perspective on Pruritus as a Health Problem
Hypothetical Patient Management on Pruritus

PBL and Distance Learning on Skin and Soft Tissue Problems

SWU-MHAM-CM