Pearls

Problematic pruritus: Seeking a cure for psychogenic itch

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Psychogenic itch—an excessive impulse to scratch, gouge, or pick at skin in the absence of dermatologic cause—is common among psychiatric inpatients, but can be challenging to assess and manage in outpatients. Patients with psychogenic itch predominantly are female, with average age of onset between 30 and 45 years.1 Psychiatric disorders associated with psychogenic itch include depression, obsessive-compulsive disorder, anxiety, somatoform disorders, mania, psychosis, and substance abuse.2 Body dysmorphic disorder, trichotillomania, kleptomania, and borderline personality disorder may be comorbid in patients with psychogenic itch.3

Characteristics of psychogenic itch

Consider psychogenic itch in patients who have recurring physical symptoms and demand examination despite repeated negative results. Other indicators include psychological factors—loss of a loved one, unemployment, relocation, etc.—that may be associated with onset, severity, elicitation, or maintenance of the itching; impairments in the patient’s social or professional life; and marked preoccupation with itching or the state of her (his) skin. Characteristically, itching can be provoked by emotional triggers, most notably during stages of excitement, and also by mechanical or chemical stimuli.

Skin changes associated with psychogenic itch often are found on areas accessible to the patient’s hand: face, arms, legs, abdomen, thighs, upper back, and shoulders. These changes can be seen in varying stages, from discrete superficial excoriations, erosions, and ulcers to thick, darkened nodules and colorless atrophic scars. Patients often complain of burning. In some cases, a patient uses a tool or instrument to autoaggressively manipulate his (her) skin in response to tingling or stabbing sensations. Artificial lesions or eczemas brought on by self-
manipulation can occur. Stress, life changes, or inhibited rage may be evoking the burning sensation and subsequent complaints.

Interventions to consider

After you have ruled out other causes of pruritus and made a diagnosis of psychogenic itch, educate your patient about the multifactorial etiology. Explain possible associations between skin disorders and unconscious reaction patterns, and the role of emotional and cognitive stimuli.

Moisturizing the skin can help the dryness associated with repetitive scratching. Consider prescribing an antihistamine, moisturizer, topical steroid, antibiotic, or
occlusive dressing.

Some pharmacological properties of antidepressants that are not related to their antidepressant activity—eg, the histamine-1 blocking effect of tricyclic antidepressants—are beneficial for treating psychogenic itch.4 Sedating antihistamines (hydroxyzine) and antidepressants (doxepin) may help break cycles of itching and depression or itching and scratching.4 Tricyclic antidepressants also are recommended for treating burning, stabbing, or tingling sensations.

Disclosure

Dr. Jain reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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