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Elderly patients with itch

Dr Elizabeth Ogden offers some practical advice gained from her experience as both an associate specialist and a GP with a special interest in dermatology

Dr Elizabeth Ogden offers some practical advice gained from her experience as both an associate specialist and a GP with a special interest in dermatology

1 Bear in mind the many different causes of itch. The causes of itch fall into six main categories: skin disease, systemic disease, infestations, medication-related, manifestations of psychiatric/psychological state and idiopathic.

The two most common reasons for itch are the dry skin of old age and iron deficiency anaemia. About 20% of elderly people have a dermatosis – mainly eczema and psoriasis, though lichen planus, bullous pemphigoid and fungal infections are also common. About 30% will have a metabolic cause and 50% fall into the more difficult to diagnose psychiatric/ psychological and idiopathic category.

2 Several factors make older skin susceptible to itch. Elderly skin is thinner, more fragile, has less collagen, shows a slower inflammatory response, has slower nerve conduction, less vasodilatation, is more affected by chemicals, has larger corneocytes and a slower transit time.

All these factors lead to the older skin being more susceptible to itch. Also, older skin is less able to retain water and is therefore drier and more likely to itch than younger skin.

3 Know which common drugs cause itch. The commonly used drugs that cause itch are opiates, aspirin, ACE inhibitors, gold, tricyclic antidepressants and statins. It is also worth remembering that diuretics can contribute to skin dryness. The onset of itch usually occurs within three to six months after a drug has started to be taken.

4 Know the right questions to ask to establish cause. Useful questions to ask would include: When did it start? Where does it itch? When does it itch? Is it worse at night? Is it worse after bathing or when warm? Does anything help relieve the itch or make it worse? Have there been any previous skin problems?

5 Be wary of skin damage due to scratching when examining the patient. The most important thing to look for is any sign of skin disease. But if the patient has got widespread itch and scratches a lot, it can be difficult to determine whether there is an underlying skin problem.

Pay particular attention to elbows, knees, scalp and nails to look for plaques of psoriasis. Dryness of the skin is very common and can often best be seen on the lower legs where it can look like crazy paving – eczema craquelé.

6 Look for the butterfly sign on the back. As most patients cannot reach the upper mid-back area between the scapula an examination of this area can help ascertain if a skin disease is present, because any lesions found in that area are unlikely to have been caused by scratching.

Conversely, if the skin there is clear but the surrounding area is damaged, this is a strong indicator that the problem is metabolic, psychiatric/psychological or an idiopathic one. This skin area is called the ‘butterfly sign' and in the elderly it can be quite large.

7 If cause of itch is not immediately apparent a few simple tests can help to tease out whether it may be metabolic. These are FBC, ferritin, urea and electrolytes, LFT and thyroid function tests. Additionally, a chest X-ray and a urinary dipstick should be considered. Iron deficiency can occur even in the presence of normal haemoglobin so a full blood count alone is not enough. Thyroid problems – both hypo and hyper – can also cause itching.

8 Make the patient aware of what they can do themselves to help itch. Itchy skin can start to become a problem when the person is admitted to a care home where low humidity, enthusiastic bathing and synthetic clothing can all contribute to the onset of the condition.

To help reduce itch, excessive bathing in hot water and the use of soap should be avoided and replaced with cooler bathing and use of a soap substitute.

Keeping nails short, avoiding synthetic clothing and not having the heating on full can help too. Increasing the humidity level, if possible, will also make patients feel a lot more comfortable. Another useful tip if the itch is very severe is to try to gate out the itch with a 1% menthol moisturiser such as aqueous cream.

9 Consider underlying malignancy. Elderly patients often express concern about whether there could be a serious illness underlying the condition.

Most widespread pruritus is due to a dermatosis rather than an underlying disease and, although malignancy can present with intractable itching, this is uncommon. Generalised itch in younger patients is more likely to be associated with malignancy.

However, there are recorded cases of itch starting years before the diagnosis of a cancer which then disappears after treatment of a tumour only to return on relapse, so tumours need to be borne in mind. It would, however, be impractical to carry out extensive investigations on every case of pruritus, so other symptoms suggestive of cancer need to be sought.

10 No cause can be found for a large number of cases. For a high percentage of cases of itch in the elderly no satisfactory explanation can be given. Loneliness and boredom can give rise to an increased awareness of itchiness, while depression and anxiety often lead to compulsive scratching.

Antidepressants can help, both the tricyclics and the SSRIs. Topical dothiepin can be very useful and has been shown to decrease itch by about half.

Capsaicin cream can be used topically for a localised area of itch such as notalgia paraesthetica, which occurs on one side of the back just below the shoulder blade and is thought to be caused by nerve damage.

Dr Elizabeth Ogden is a dermatology GPSI in Potters Bar, Hertfordshire, and an associate specialist in dermatology

Competing interests None declared

About 20% of elderly people have a dermatosis – mainly eczema and psoriasis Psoriasis

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