Pruritus Ani

Description:
• Centered on anal or genital area, minimal or no pruritus elsewhere
• Bleeding may be induced due to scratching
• Manifestations are identical to lichen simplex chronicus elsewhere on the body
Causes:
• Dermatologic diseases:
o Allergic contact dermatitis – common; due to meds, tissue fragrance or preservatives
o Seborrheic dermatitis, psoriasis, lichen planus, lichen sclerosis, atopic dermatitis, extramammary Paget
disease, Bowen disease
• Local irritants:
o Irritant contact dermatitis from GI contents (ex. hot spices, cathartics)
o Failure to cleanse area adequately after bowel movements
o Leakage of rectal mucus onto perianal skin due to anatomic factors
o Physical changes (hemorrhoids, anal tags, fissures, fistulas)
• Infectious agents:
o Mycotic pruritus ani – C. albicans, E. floccosum, T. rubrum
▪ Fissures, white sodden epidermis
▪ Look for other sites of fungal infection (groin, toes, nails)
o Erythrasma - Corynebacterium minutissimum
o B-hemolytic streptococcal infections (especially in young children)
o Pinworm infestation – nocturnal pruritus
o Intestinal parasites – T. solium, T. saginata, S. stercoralis, amebiasis
o Pediculosis pubis – itching most severe on the pubic area
o Scabies – look for involvement of the finger webs, wrists, axillae, areolae, genitalia
• Others:
o Tetracyclines (due to predisposition to candidiasis)
o Diabetes (due to predisposition to candidiasis)
o Lumbosacral radiculopathy – assess via radiographs and nerve conduction studies, treat via
paravertebral blockade

Treatment:
• Meticulous toilet care irregardless (lol) of cause
o Mild soap and water or wet toilet tissue
o Medicated cleansing pads
o Emollient lotion
• Treatment depends on etiologic agent!
o Noninfectious – topical corticosteroids effective, topical tacrolimus ointment safer, pramoxine
(nonsteroidal topical anesthetic) + hydrocortisone in lotion form
• Sometimes it is best to discontinue all topical meds and treat with plain water sitz baths, followed immediately
by plain petrolatum applied over wet skin

Pruritus Vulvae

Description:
• Pruritus focused on the vulva, counterpart of pruritus scroti
• Check if the inguinal, perineal, and perianal areas are also affected
• Check for burning – if (+), evaluate for sensory neuropathy
Causes:
• Unspecified dermatitis – most common
• Lichen sclerosus – frequently seen in middle-age and elderly women
• Chronic vulvovaginal candidiasis – vaginal candidiasis is a frequent cause

VHCC 3A-MED | ANDREW’S 13TH ED + LECTURE NOTES (★)

 • Dysesthetic vulvodynia
• Psoriasis – least common
• Irritant – common in prepubertal children
• Pregnancy, oral antibiotic intake – due to predisposition to candidiasis
• T. vaginalis infection
• Contact dermatitis – sanitary pads, contraceptives, douche solutions, fragrance, preservatives, colophony,
benzocaine, corticosteroids, partner’s condoms
• Urinary incontinence
• Lichen planus – mucosal changes may occur with pruritus (erosions, ulcerations, resorption of labia minora,
atrophy)
Treatment:
• *Candidiasis and Trichomonas treatments discussed in another chapter (kaya niyo na yan)
• Lichen sclerosus – pulsed dosing of high-potency topical steroids, topical tacrolimus or pimecrolimus
• Psychogenic pruritus, irritant or allergic reactions:
o Topical steroids, topical tacrolimus, high-potency topical steroids
o Use silk fabric underwear
o Topical lidocaine, topical pramoxine, oral tricyclic antidepressant
o Phototherapy
• Any chronic skin disease that does not respond to therapy should prompt a biopsy!

Pruritus Scroti

Description:
• Pruritus focused on the scrotum, usually on the dependent surfaces
• Lichenification may result, can be extreme, and may persist for years despite therapy

Causes:
• Circumscribed neurodermatitis (lichen simplex chronicus)
• Psychogenic pruritus – most frequent type
• Infectious causes – less common than idiopathic causes
o Fungal infections, except candidiasis, usually spare the scrotum
o Candidiasis – look for burning as the primary symptom and an eroded, weepy, or crusted scrotum
o Pruritus ani – scrotum affected to a lesser degree, usually midline is affected (extends from anus along
the midline to the base of the scrotum)
• Allergic contact dermatitis – topical meds like steroids

Treatment:
• Topical corticosteroids – mainstay
o Watch out for “addicted scrotum syndrome” due to high-potency topical steroids
o Severe burning and redness may occur after attempts to wean patients off steroids, usually seen after
chronic use
o Can also taper to less potent corticosteroids instead
• Topical tacrolimus ointment – useful in overcoming the effects of overuse of potent topical steroids
• Other useful nonsteroidal alternatives – topical pramoxine, doxepin, simple petrolatum (applied after a sitz
bath, especially for pruritus ani)

Internal Causes of Pruritus

Causes:
• Liver disease, especially obstructive and hepatitis C
o Check for jaundice and color of stool/urine (★)
• Renal failure
o Check for anorexia, weight loss, changes in bladder habits, edema, dyspnea, change in urine color (★)
• Diabetes mellitus
VHCC 3A-MED | ANDREW’S 13TH ED + LECTURE NOTES (★)
 • Hypothyroidism and hyperthyroidism
o Check for palpitations, heat/cold intolerance, weight loss (★)
• Hematopoietic diseases (ex. iron deficiency anemia, polycythemia vera)
o Check for dizziness and weight loss (★)
• Neoplastic diseases (ex. lymphoma, especially Hodgkin disease and cutaneous T-cell lymphoma, leukemia,
myeloma)
o Hodgkin disease – usually continuous, sometimes accompanied by severe burning
o Leukemia, except for chronic lymphocytic leukemia, tends to be less severe than Hodgkin disease
• Internal solid-tissue malignancies
o Look for generalized pruritus that is unexplained by skin lesions
• Intestinal parasites
• Carcinoid
• Multiple sclerosis
• AIDS
• Connective tissue disease (particularly dermatomyositis)
• Neuropsychiatric diseases (especially anorexia nervosa)
• Dry skin – xerosis (★)

Laboratory tests used to rule out diseases: (★)

• Liver function tests, CBC, renal function tests, urinalysis, BUN, creatinine, TSH, fecalysis (check for parasites), FBS
• If normal, suspect xerosis

Chronic Kidney Disease

Description:
• Most common systemic cause of pruritus
• Pruritus often generalized, intractable, and severe
• Dialysis-associated pruritus may be episodic, mild, or localized to the dialysis catheter site, face, or legs
• Most have concomitant xerosis
• Patients on peritoneal dialysis have a lower severity of pruritus vs hemodialysis

Cause:
• Multifactorial (xerosis, secondary hyperparathyroidism, increased serum histamine levels, hypervitaminosis A,
iron deficiency anemia, neuropathy)

Treatment:
• Emollients – for xerosis
• Gabapentin – low initial dose of 100 mg after each session with slow upward titration, given three times weekly
at the end of hemodialysis sessions
• Narrow-band UVB phototherapy, but broad-band UVB may be best
• Nalfurafine, 5 µg once daily after supper
• Thalidomide, intranasal butorphanol, IV lidocaine – less practical options
• Renal transplant – eliminates pruritus

Biliary Pruritus
Description:
• Look for jaundice and severe generalized pruritus
• Pathophysiology not well understood but linked to lysophosphatidic acid

Cause:
• Chronic liver disease with obstructive jaundice
• Intrahepatic cholestasis of pregnancy
• Primary sclerosing cholangitis
• Hereditary cholestatic diseases such as Alagille syndrome
• Primary biliary cirrhosis (has many other cutaneous manifestations)
• Hepatitis C infection

VHCC 3A-MED | ANDREW’S 13TH ED + LECTURE NOTES (★)

 Treatment (for pruritus secondary to chronic cholestatic liver disease):
• Cholestyramine 4-16 g daily
• Rifampin, 150 to 300 mg/day – use with caution because it may cause hepatitis
• Naltrexone, up to 50 mg/day – has significant side effects; start at ¼ tablet (12.5 mg) and increase by ¼ tablet
every 3-7 days until pruritus improves
• Sertraline, 75 to 100 mg/day
• UVB phototherapy
• Ursodeoxycholic acid – effective only for pruritus in intrahepatic cholestasis of pregnancy
• Liver transplant – definitive treatment with dramatic relief

Biliary Pruritus secondary to Primary Biliary Cirrhosis

Description:
• Occurs almost exclusively in women older than 30
• Itching may begin insidiously and may be the presenting symptom, and extreme pruritus develops with time
o Disease is relentlessly progressive with development of hepatic failure
o Scleroderma can also accompany it
• Look for accompanying jaundice and a striking melanotic hyperpigmentation of the entire skin with a striking
melanotic hyperpigmentation of the entire skin
• Also look for eruptive xanthomas, planar xanthomas of the palms, xanthelasma, and tuberous xanthomas over
the joints
• Dark urine, steatorrhea, and osteoporosis may also be present
• Serum bilirubin, alkaline phosphatase, serum ceruloplasmin, serum hyaluronate, and cholesterol values are
increased, and antimitochondrial antibody test is positive

Polycythemia Vera
Description:
• Usually induced by temperature changes or several minutes after bathing
• Unknown cause

Treatment:
• Aspirin – immediate relief, risk of hemorrhagic complications
• PUVA, NB UVB – marked improvement is noted after an average of six treatments, with complete remission
often occurring in 2–10 weeks
• Paroxetine, 20 mg/day
• Interferon alpha-2 – effective in treating underlying disease

Lichen Simplex Chronicus (Circumscribed Neurodermatitis)

Description:
• Results from vigorous long-term chronic rubbing and scratching, with the skin becoming thickened and
leathery
o Onset usually gradual and insidious
o Scratching becomes a habit
o Paroxysmal pruritus is the main symptom
o Lichenification:
▪ Normal markings of skin become exaggerated
▪ Striae form a crisscross pattern, producing a mosaic in between composed of flat-topped,
shiny, smooth quadrilateral facets
• Eruption may be papular, resembling lichen planus, but the patches can also be excoriated, slightly scaly or
moist, and rarely, nodular
• Common areas affected:
o Technically any site of the body may be affected
o Predilection for the back and sides of the neck, the scalp, the upper eyelid, the orifice of one or both
ears, the palm, soles, or often the wrist and ankle flexures
o Vulva, scrotum, and anal areas are also common sites
VHCC 3A-MED | ANDREW’S 13TH ED + LECTURE NOTES (★)
 Causes:
• Underlying diseases (ex. atopic or allergic contact dermatitis, ringworm)
• Anxiety disorders, depression, erectile dysfunction

Treatment:
• Stress the need to avoid scratching
• High-potency steroid cream or ointment should be used initially but not indefinitely – steroid-induced atrophy
o Occlusion of medium-potency steroids
o Steroid-containing tape
o Taper down as lesions resolve
• Topical doxepin, capsaicin, or pimecrolimus cream or tacrolimus ointment – good adjunctive therapy
• Intralesional injections of triamcinolone suspension 2.5–5 mg/mL
o Do not inject into infected lesions, may cause abscess
• Botulinum toxin A injection
• Complete occlusion with an Unna boot – most severe cases

Prurigo Nodularis/Mitis
Description:
• Presence of multiple itchy nodules mainly on the extremities, especially on the anterior surfaces of the thighs
and legs
o Commonly a linear arrangement
o Individual lesions are pea sized or larger, firm, and erythematous or brownish
o When lesions are fully developed, they become verrucous or fissured
o Itching is severe but usually confined to the lesions themselves
• Course of disease is chronic, and the lesions develop slowly
• Stress commonly causes bouts of extreme pruritus
o Pruritus is characteristically paroxysmal
o Pruritus is intermittent, unbearably severe, and relieved only by scratching to the point of damaging the
skin, usually inducing bleeding and often scarring
• Clinically confused with pemphigoid nodularis
• Histologic finding:
o Compact hyperkeratosis
o Irregular acanthosis
o Multinucleated keratinocytes
o Perivascular mononuclear cell infiltrate in the dermis
o Dermal collagen may be increased, especially in the dermal papillae, and subepidermal fibrin may be
seen – evidence of excoriation
o Transepidermal elimination of degenerated collagen – cases of renal failure

Causes:
• Unknown, but multiple factors may contribute
o Atopic dermatitis, hepatic diseases, hepatitis C infection, HIV disease, pregnancy, renal failure,
lymphoproliferative disease, stress, insect bites
Treatment:
• Intralesional or topical administration of steroids – initial treatment of choice
o Usually eradicates individual lesions, but not as effective if disease is extensive
• Steroids in tape, prolonged occlusion with semipermeable dressings
• PUVA, NB UVB, and UVA alone
• Combination product containing calcipotriene and betamethasone dipropionate ointment, calcitriol ointment,
or tacrolimus ointment applied topically twice daily
• Isotretinoin 1 mg/kg/day for 2–5 months
• Managing dry skin with emollients and avoidance of soap, with administration of antihistamines,
antidepressants, or anxiolytics
VHCC 3A-MED | ANDREW’S 13TH ED + LECTURE NOTES (★)
 • Thalidomide, lenalidomide, pregabalin, cyclosporine
o Thalidomide – initial dose 100 mg/day, titered to the lowest dose required
▪ Onset may be rapid or slow and sedation may occur
▪ Risk for developing a dose-dependent neuropathy at cumulative doses of 40–50 g
o Lenalidomide – less problems with neuropathy but may cause myelosuppression, venous thrombosis,
and Stevens-Johnson syndrome
o Pregabalin 75 mg/day for 3 months
o Cyclosporine 3–4.5 mg/kg/ day
• Methotrexate 7.5–20 mg weekly
• Cryotherapy
• Multimodal therapy (topical + systemic therapies)

Acne Vulgaris (★)

(book chapter too long – just read the trans on this and focus on appearance of lesions, associated s/s, causes (if
meron), differentials, and treatment)

Treatment:
• Mild (comedonal) – retinoid (adapalene)
• Oral antibiotics – tetracycline is the safest and cheapest choice (antibiotic of choice)

Miliaria Pustulosa

Description:
• Miliaria – retention of sweat because of occlusion of eccrine sweat ducts, producing an eruption that is
common in hot, humid climates
• Miliaria pustulosa – preceded by another dermatitis that has produced injury, destruction, or blocking of the
sweat duct
o Pustules are distinct, superficial, and independent of the hair follicle
o Sterile pustules rather than erythematous papules (★)
o Pruritic pustules occur most frequently on the intertriginous areas, flexural surfaces of the extremities,
scrotum, and back of bedridden patients
• Associated diseases: contact dermatitis, lichen simplex chronicus, intertrigo
o Suspect type I pseudohypoaldosteronism if with recurrent episodes – salt-losing crises may precipitate
miliaria pustulosa
Cause:
• S. epidermidis, due to the production of an extracellular polysaccharide substance

Treatment:
• Place patient in a cool environment – most effective
• Anhydrous lanolin – resolves the occlusion of pores, may help to restore normal sweat secretions
• Hydrophilic ointment – helps dissolve keratinous plugs, facilitates the normal flow of sweat
• Soothing, cooling baths containing colloidal oatmeal or cornstarch – use in moderation
• Dusting powders (ex. cornstarch or baby talcum powder) – for mild cases
• NSS compress to dry up the lesion (★)

Bacterial Folliculitis
Description:
• Infection of the hair follicles
o Fragile, yellowish white, domed pustules develop in crops and heal in a few days
o If bacterial – may initially present as erythematous papule with pain, then pustules will appear around
hair follicles (★)
o If it becomes bigger and deeper = furuncle/carbuncle

VHCC 3A-MED | ANDREW’S 13TH ED + LECTURE NOTES (★)

 • Superficial pustular folliculitis (impetigo of Bockhart) – superficial folliculitis with thin-walled pustules at the
follicle orifices
o Susceptible locations: extremities and scalp, face (especially periorally)
• Staphylococcal folliculitis – can affect any hair-bearing areas
o Most often on the trunk and extremities
o May also affect the eyelashes, axillae, pubis, and thighs
o Beard area – sycosis vulgaris (sycosis barbae)
o Pubis – may be considered an STD
• Sycosis vulgaris – a.k.a. barber’s itch or sycosis barbae
o Perifollicular, chronic, pustular staphylococcal infection of the bearded region characterized by
inflammatory papules and pustules, and a tendency to recurrence
o Disease begins with erythema and burning or itching, usually on the upper lip near the nose
o In 1 or 2 days, one or more pinhead-sized pustules, pierced by hairs, develop
o These pustules then rupture after shaving or washing and leave an erythematous spot, which is later
the site of a fresh crop of pustules
o Therefore, the infection persists and gradually spreads, at times extending deep into the follicles
o A hairless, atrophic scar bordered by pustules and crusts may result
o Marginal blepharitis with conjunctivitis – severe cases
o Look for concomitant AIDS
Causes:
• S. aureus infection – most common cause
• Other bacteria are also etiologic agents

Treatment: (trans-based)
• Gram negative folliculitis:
o Isotretinoin – suppresses sebum production and dries out mucus membranes
o Once folliculitis has responded, residual acne must be treated with retinoic acid, benzoyl peroxide,
cryotherapy, and other therapies
• P. aeruginosa folliculitis:
o Self-limited, clears in 2-10 days
o Acetic acid 5% compresses – symptomatic relief
• Staphylococcal folliculitis:
o Deep lesions must be drained, superficial pustules will rupture and drain spontaneously
o Bacitracin or mupirocin ointment
o 1st generation cephalosporin – for failed drainage or topical treatment or accompanying soft tissue
infection
o Anhydrous aluminum chloride – for chronic cases
• Superficial pustular folliculitis:
o Topical antibiotics – apply only when needed; mupirocin 2% cream or ointment, retapamulin 1%
ointment, fusidic acid
o Systemic antibiotics – generalized or severe infections

Ecthyma

Description:
• Ulcerative streptococcal or less commonly staphylococcal pyoderma
o Staphylococcal pyoderma – urban setting, seen in IV drug users and HIV patients
• Begins with a vesicle or vesicopustule, which enlarges and in a few days becomes thickly crusted
o Streptococcal vesicles may mimic HSV, especially in the setting of atopic dermatitis
o When crust is removed, there is a superficial, saucer-shaped ulcer with a raw base and elevated edges
o Lesions tend to heal after a few weeks, leaving scars
o Lesions may also proceed to gangrene if resistance is low – look for a focus of pyogenic infection
elsewhere

VHCC 3A-MED | ANDREW’S 13TH ED + LECTURE NOTES (★)

 • Local adenopathy may be present

Cause:
• Uncleanliness, malnutrition, trauma – predisposing causes

Treatment:
• Cleansing with soap and water after soaking off the crust with compresses
o Follow with application of mupirocin, retapamulin, or bacitracin ointment, twice daily
• Oral dicloxacillin or a first-generation cephalosporin – adjust according to susceptibilities

Pyogenic Paronychia
Description:
• Inflammatory reaction involving the folds of the skin surrounding the fingernail
• Characterized by acute or chronic tender, and painful swelling of the tissues around the nail
o Will first be red and then pustular, caused by an abscess in the nailfold
o Chronic infection – horizontal ridges appear at the base of the nail
o New ridges appear with recurrences
• Look at patient history – bartenders, food servers, nurses, occupations involving constantly wet hands
• If abscess is suspected, apply light pressure with the index finger against the distal volar aspect of the affected
digit – better demonstrates extent of collected pus by inducing well-demarcated blanching
• Mimicker: myrmecial warts, psoriasis (will have swelling of nail fold plus nail changes, nail tipping, salmon
patches) (★)

Causes:
• Separation of the eponychium (cuticle) from the nail plate – primary predisposing factor
o Usually due to trauma as a result of moisture-induced maceration of the nailfolds from frequent
wetting of the hands
o The moist grooves of the nail and nailfold become secondarily invaded by pyogenic cocci and yeasts
• Atopic dermatitis (in children)
o Inoculation of bacteria under the nail by scratching infected atopic dermatitis
o Look for paronychia of the distal finger under the nail
• Causative bacteria:
o S. aureus – acute abscess formation, most common bacterial cause (★)
o S. pyogenes – erythema and swelling
o Pseudomonas species
o Proteus species
o Anaerobes
o C. albicans – most frequent pathogenic yeast; chronic swelling
Treatment:
• Protection against trauma + concentrated efforts to keep affected fingernails dry – mainstay of treatment
o Use rubber or plastic gloves over cotton gloves
• Incision and drainage – acutely inflamed pyogenic abscesses
• Oral semisynthetic penicillin or cephalosporin with excellent staphylococcal activity – acute suppurative
paronychia, especially if stains show pyogenic cocci
o Cephalexin – covers S. aureus and S. pyogenes; 500 mg 4x a day q6 for adults, 25-50 mg/kg/day q6 for
pediatric patients (★)
o Cloxacillin will not work against S. pyogenes (★)
o Suspect MRSA or mixed-anaerobic bacterial infection if ineffective!
• Topical or oral antifungals – only cure ~50% of cases caused by Candida
o Topical corticosteroids – higher cure rate due to decreased inflammation to allow tissue repair
o Usually antifungal liquid (ex. miconazole) + topical corticosteroid cream/ointment

VHCC 3A-MED | ANDREW’S 13TH ED + LECTURE NOTES (★)

 Generalized Pustular Psoriasis (von Zumbusch Psoriasis)

Description:
• Typical patients have plaque psoriasis and often psoriatic arthritis
o These are non-infectious, sterile, and no organism is obtained in Gram stain (★)
• Onset is sudden, pruritus and intense burning often present
• Formation of lakes of pus periungually, on the palms, and at the edge of psoriatic plaques
o Erythema occurs in the flexures before the generalized eruption appears
o This is followed by a generalized erythema and more pustules
• Mucous membrane lesions are common
o Lips may be red and scaly
o Superficial ulcerations of the tongue and mouth, geographic or fissured tongue
• Patient is frequently ill – fever, erythroderma, hypocalcemia, cachexia
o Associated with acute respiratory distress syndrome
o Other systemic complications – pneumonia, congestive heart failure, hepatitis
• Presenting sign of Cushing disease – generalized pustular psoriasis
• Look for strong familial history of psoriasis

Causes:
• Episodes often provoked by withdrawal of systemic corticosteroids
o Episodic event may punctuate the course of localized acral pustular psoriasis
• Meds – iodides, coal tar, terbinafine, minocycline, hydroxychloroquine, acetazolamide, salicylates
• Idiopathic – infants and children
Treatment:
• Acitretin – drug of choice for severe disease, rapid response
• Isotretinoin
• Cyclosporine, methotrexate, biologic agents – alternatives
• Dapsone 50-100 mg/day

Candidal Intertrigo

Description:
• Arise between the folds of the genitals; in groins or armpits; between the buttocks; under large, pendulous
breasts; under overhanging abdominal folds; or in the umbilicus
• Pink to red, intertriginous moist patches, surrounded by a thin, overhanging fringe of somewhat macerated
epidermis (“collarette” scale)
o May resemble tinea cruris, but there is usually less scaliness and a greater tendency to fissuring
o Persistent excoriation and subsequent lichenification and drying may modify the original appearance
over time
o Tiny, superficial, white pustules sometimes observed closely adjacent to the patches (satellite
papules/pustules) (★)
• For KOH, scrape around the satellite lesions and look for characteristic hyphae/budding/pseudohyphae (★)
• When present, Candida can cause flares of inverse psoriasis, although prevalence of Candida is not increased in
the intertriginous areas of patients with either psoriasis or atopic dermatitis

Treatment:
• Topical anticandidal preparations – usually effective but recurrence is common
o Do not use if (+) systemic manifestations (★)
• Combination topical anticandidal agent + midstrength corticosteroid – may lead to more rapid relief
• Antifungals – broad spectrum azoles, like miconazole (★)
o Use oral antifungals (ex. itraconazole, fluconazole) especially if immunocompromised
• Castellani paint (colorless paint)
• Terbinafine DOES NOT work for Candida

VHCC 3A-MED | ANDREW’S 13TH ED + LECTURE NOTES (★)