April 16, 2009

I Itch, Therefore I Am: Confessions of a Scratchaholic

Did God who gave us flowers and
Also provide the allergies?
E. Y. Harburg 1898-1981: “A Nose is a Nose is a Nose” (1965)
In a summer blog, I discussed a New Yorker story by Atul Gawande about itching. It spoke of woman who had itched through her skull to her brain.
“One morning, after she was awakened by her bedside alarm, she sat up and, she recalled, ‘this fluid came down my face, this greenish liquid.’ She pressed a square of gauze to her head and went to see her doctor again. M. showed the doctor the fluid on the dressing. The doctor looked closely at the wound. She shined a light on it and in M.’s eyes. Then she walked out of the room and called an ambulance. Only in the Emergency Department at Massachusetts General Hospital, after the doctors started swarming, and one told her she needed surgery now, did M. learn what had happened. She had scratched through her skull during the night—and all the way into her brain.”

While the story interested me as it pertained to BIID, it now interests me in that it pertains to me. For you see, I itch.

When I mentioned this to my band mates, S. informed me that she had also had a skin problem. I asked if it had itched and how badly. “Itch would be the wrong word,” she said. “It was as if gouging myself to the bone would be wholly inadequate to my relentless need to scratch.” “It was,” she said, “an urge so irresistible as to negate all willpower.”

In the 4/7/09 New York Times, Benedict Carey writes: “Scientists argue that itching is most likely related to grooming, and evolved to protect animals against some toxic plants, as well as insects, along with the diseases they can transmit, like malaria, yellow fever and river blindness. But the biology of itch has been a mystery, and neglected for years by researchers, who have been far more focused on pain.

Some 50 diseases leave people in a misery of itching which usually cannot be treated. Studies among kidney disease patients and psychiatric inpatients have found that itch is among the top complaints. And when it is severe it keeps people up at night, often worsening their condition.”

Fearing the sudden appearance of small, raised red welts had something to do with cancer or liver problems, I contacted my trusted physician. The doc thought it looked like folliculitis, an infection of the hair follicles. The follicle is the tiny pouch each hair grows out of. Where there’s hair, there’s the possibility of folliculitis, although it is most common to the face, scalp, and areas rubbed by clothing, such as the thighs and groin. But she insisted that I see the dermatologist that afternoon just to be sure. After the usual interrogation by a resident or two, the skin doc comes in, looks me over, and declares it a simple case of dermatitis - nothing to do with my liver or lymphoma. This from the Mayo Clinic site: “Dermatitis is a general term that describes an inflammation of the skin. There are different types of dermatitis, including seborrheic dermatitis and atopic dermatitis (eczema). Though the disorder can have many causes and occur in many forms, it usually involves swollen, reddened and itchy skin.”

Cool, no problem, so I’ve got dermatitis. As French would say, “let’s guzzle! The doc prescribes a corticosteroid cream, clobetasol propionate, an antihistamine, cetirizine hydrochloride (Zyrtec), and assures me my troubles will soon be over. Should my condition persist for longer than 3 weeks, however, she tells me to notify U-M Dermatology and they’ll re-examine me. Well, as is so often the case, the symptoms temporarily ebbed, and I assumed my skin would clear. It didn’t.

At first, yes, the symptoms flared down (If things can flare up, then can’t they flare down? And yes, I do recognize the phrase is oxymoronic), and I thought there was improvement; but as with many of the maladies that come with age, it persisted.

I knew what I had to do – google it.

After getting on the internet, I was sure it was Lichen Planus.

After calling U-M dermatology back, fervently hoping my phone call will be in within the time frame whereby I don’t have to go through that dreaded referral process of having my Primary Care Physician contact them first, an appointment is scheduled for the next day. Cool. The same skin doc looks at me again and firmly assures me that, yes, they know what Lichen Planus is, and, no, this ain’t it. They now admit, however, that these things can last a while, if not become chronic. Oh boy!

Now who am I to second guess the experts. So I get some more ointment (I like that word, just say it, ointment, it sounds like what it is, oooointment), stock up on Zyrtec (24 hour otc allergy relief) and have at it again. Well, it’s stable right now, but I’m reasonably sure that they were wrong and I’m right. What’s described below is exactly what I saw when I examine myself. If you google this condition you’ll see photos. I haven’t gone back for a third visit, but note the last sentence of the paragraph below: “While the typical appearance of LP makes the disease somewhat easy to identify, a skin biopsy may be needed to confirm the diagnosis.”

According to the American academy of Dermatology: “Lichen Planus of the skin is characterized by reddish-purple, flat-topped bumps that may be very itchy. Some may have a white lacy appearance called Wickham's Striae. They can be anywhere on the body, but seem to favor the inside of the wrists and ankles. The disease can also occur on the lower back, neck, legs, genitals, and in rare cases, the scalp and nails. LP on the legs is usually much darker in appearance. There may be thick patches (hypertrophic LP) especially on the shins. Blisters are rare except in special cases called bullous LP. While the typical appearance of LP makes the disease somewhat easy to identify, a skin biopsy may be needed to confirm the diagnosis.”

Here’s the good news, if you want to call it that. The condition typically goes away, although it can last for a couple of years. And get this, the treatment is exactly the same as the plan I’ve been on, steroid cream and antihistamines. Oh well, such is life.

Here’s a cool piece on itching I found on google scholar (just move right at the top of the screen where it says, Web, Images etc, to “More,” and scroll down to “Scholar”).

Seventh Age Itch


Professor of Dermatology,
Royal Infirmary,Edinburgh EH

"Sans teeth, sans eyes, sans taste, sans everything."' Shakespeare knew that blunting of the senses was one of the hallmarks of old age, but there is one exception-itch. All too often it appears or is exaggerated in the elderly. Pruritus is synonymous with itch but when used as a diagnostic term is applied to patients whose itch is unaccompanied by any visible primary skin disease.

Many such elderly patients have little to see on their skins, but excluding a primary skin disorder is not as easy as it might seem since scratching may have caused more than scratch marks."Prurigo" is an ill defined term which describes the excoriated pink papules which are often seen on itchy skin and which seem to be due to scratching.

Lichenification-thickened skin looking like Morocco leather-is also due to prolonged scratching and rubbing. Similarly, purpura, broken hairs,and pigmentation may be secondary to repeated trauma. On the other side of the coin, even the use of a lens will not prevent trained doctors with intact sensory faculties from falling into some common traps.

All of us can tell embarrassing stories about missing scabies in clean people, forgetting to ask about infested pets, overlooking underclothes crawling with lice, omitting to check for contact with fibreglass, disregarding minor eczema, and failing to appreciate the existence of conditions such as winter itch and aquagenic pruritus.
Even when these have been considered, however, many elderly patients still have no recognizable skin disease responsible for their itching. Between 16% and 50%of patients investigated for pruritus have an underlying systemic disease.

Well established causes are obstructive jaundice, chronic renal failure, pregnancy, thyroid disease, lymphoma, carcinomatosis, iron deficiency anaemia, intestinal parasites, and diabetes.' Rarer causes include polycythaemia, haemochromatosis, brain tumours (especially those infiltrating the floor of the fourth ventricle), and drugs such as cocaine, morphine, and chloroquine.

It follows that if a cause for the pruritus is still not evident aftera good history and examination of the skin, then a detailed physical examination and some screening tests are needed. Investigations should include testing the urine for sugar and protein, a complete blood count and sedimentation rate, blood urea and liver function tests, thyroid function tests,examination of the stools for occult blood and parasites, and a chest radiograph.
If these give no answer xerosis or mild asteatotic eczema should be considered again but a hard core of patients remain in whom no cause can be found. We must either accept that with advancing age the incidence of idiopathic pruritus becomes higher or recognise the existence of an entity,"senile pruritus," attributable perhaps to age associated degenerative changes in peripheral nerve endings. If this diagnosis is made the patient should be kept under review as an underlying cause may show up later.
When a cause is found its treatment may cure the associated itch-though in chronic renal failure and hepatobiliary disease the management of pruritus may be far from satisfactory. In the absence of a demonstrable cause then the patient should be treated symptomatically. Extremes of temperature and rough underclothing should be avoided. Adding an oil to the bath water will prevent the skin from drying out too much after bathing. Cooling applications include 05% menthol in aqueous cream. Crotamiton or amildly potent topical steroid may also be useful. Systemic antihistamines, particularly trimeprazine and hydroxyzine, are worth trying; their effect is probably due to their sedative action.

Unfortunately, these non-specific measures are often disappointing. Although for reasons of euphony Shakespeare could not have added "avec itch" to his list of changing sensory faculties, many patients and doctors know only too well that itch may be the final indignity.”

Thank you, Dr. Hunter.

That’s All Folks! - Randy


Anonymous said...

This skin stuff must be related to age. ;) I thought my bio-identical hormones were the answer! I swear I have been dealing with same. Had myself believing I would be diagnosed with my mother's non-alcoholic liver disease she died of. Dermatitis was it. Our dry hot desert air doesn't help matters. I must say my skin felt wonderful after soaking in a bath with tea tree oil. Ointment and allergy med and being patient, I guess. Even our 12 year old cat, Mr. Peaches is itching! He is getting prednizone. Itches begone!!!
Bonni Q

Michael said...

I spend my days on itch. I work for the Acologix mentioned in these articles:
and ...
With Uremic Pruritus (UP, Hmmm! I work every day in the UP too!) there are pretty clear indications, like End Stage Renal Disease, which is hard to miss. One major sign is that dialysis machine attached to you. You don't have one of those, do you?

wet wipes said...

It is bad when you have to itch and scratch the skin...consult a good dermatologist who can help and apply chemical free moisturizers that will soothe the skin.

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