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Pruritus-Itching (가려움증)

The Root of Ambulatory Care (외래 진료 지침서) 전체 목록 보기
KEYWORDS: ..긁고 싶은 욕망을 일으키는 피부의 불쾌한 감각이며, 그 원인은 Lymphoma 와 같은 심각한 질환에서부터 Flea bites같은 간단한 원인까지 다양하지만 다 행히 대부분의 pruritus는 일차적인 피부환경에서 기인한다. ..Itching is a complex psychoneurodermatologic phenomenon involving central nervous system processes and peripheral mediators but is complex and poorly understood. : histamine, neuropeptide : substance P, arachidonic acid transformation products, prostaglandin E, platelet activating factor, vasoactive peptides and proteases, enkephalin, unmyelinated C fiber 등이 관여하는 걸로 알려져 있다. Localized pruritus Scalp Seborrheic dermatitis, Psoriasis, Acne necrotica, Allergic contact dermatitis Eyelids Irritant dermatitis, Contact dermatitis, Atopic dermatitis Ears Psoriasis, Seborrheic dermatitis, Otitis externa Hands Contact or irritant dermatitis, Psoriasis, Dyshidrotic eczema Genitalis Kraurosis vulvae, Psoriasis, Fungal or yeast infection Anus Pruritus ani Legs Asteatotic dermatitis, Stasis dermatitis, Lichen simplex chronicus Feet Fungal infection, Dyshidrotic eczema, Psoriasis Generalized pruritus i. Environmental : low humidity, winter weather, electric blankets, heated mattress pads or heated water beds, frequent showering, high humidity with sweat retention ii. Chemical : some detergents or additives to the wash, certain body soaps or washes, rubbing alcohol, witch hazel, some body lotions or bath additives, topical chemical irritants iii. Particulate matter : foreign bodies such as fiber-glass or hair Pruritus- Itching External factors 443 The Root of ambulatory care iv. Infestations, bites, or parasites : scabies, lice, black flies, no-see-ums, chiggers, sand fleas, swimmer's itch, animal mites or fleas, arthropod bites v. Aquagenic pruritus vi. Radiation therapy Innumerable diseases associated with itching. i. Infection : viral disease (HIV, varicella, rubella), fungal infection, trichinosis, intestinal parasites ii. Drug eruptions : often associated with chemotherapy with antineoplastic drugs.(may cause pruritus from cholestasis, renal impairment, allergic reaction, hypersensitivity, or chemical interference with neural pathways) iii. Endocrine : hyperthyroidism, hypothyroidism, parathyroidism, diabetes, carcinoid syndrome iv. Hepatic disease : obstructive jaundice, primary biliary cirrhosis, intrahepatic or posthepatic biliary obstruction, hepatic cholestasis as seen in pregnancy v. Renal disease : chronic renal disease(13%), hemodialysis(70~90%) vi. Hematologic disease : Hodgkin’s disease(10~25%), polycythemia vera, iron deficiency, paraproteinemia, mast cell disease, myelomatosis, leukemia, mycosis fungoides vii. Occult malignancy : adenocarcinomas and squamous cell carcinomas of various organs viii. Allergies : ingestants, inhalants ix. Psychogenic factors : neurotic excoriations, delusions of parasitosis, obsessive-compulsive disorder → diagnosis by exclusion and must rule out all other causes first. x. Autoimmune disease : graft versus host disease 1. Where is the itching? → localized/generalized 2. How severe is the itching? → interference with work, sleep, or daily activities 3. When do you get the itching? → onset/duration/morning or night/time of year 4. What makes the itching worse? → cold air/stress/sun/bathing/clothing Key questions Systemic factors : Generalized pruritus중 systemic disease에 의한 것은 10%~50% 를 차지한다. Skin diseases Key tests Key treatments Pruritus- Itching 5. What are you exposed to? → pets/allergen/soaps/irritants/medications including nonprescription/ travel/occupational 6. Is anyone else in your household itching? 7. What have you tried for the itching so far? 8. Do you have any other problems? → weight loss/fever/jaundice/fatigue/night sweats - Consider those patients with significant itching, but without dermatologic disease, who have not responded to nonspecific treatment. 1. LFT/RFT/FBS/TFT 2. CBC with differential (Ferritin level) 3. Stool for OB, ova and parasites/ Chest X ray/ Malignancy workup if needed Other tests if indicated by history and physical examination ..Pruritus가 있는 환자에서 악성 종양의 발생이 특별히 증가하지는 않기 때문 에 malignancy workup은 필요시 시행한다. - General consideration (Disease independent) ..Use skin lubricants liberally: petrolatum or lubricant cream at bedtime; alcohol-free, hypoallergenic lotions frequently during the day. ..Decrease frequency of bathing and limit bathing to brief exposure to tepid water; after bathing, briefly pat skin dry and immediately apply skin lubricant. ..Use mild, unscented, hypoallergenic soap two to three times per week; limit daily use of soap to groin and axillae (spare legs, arms, and torso). ..Humidify dry indoor environment, especially in winter. ..Choose clothing that does not irritate the skin (preferably made of doubly rinsed cotton or silk) ; avoid clothing made of wool, smooth-textured cotton, or heat-retaining material (synthetic fabrics) ; when washing sheets, add bath oil (e.g., Alpha Keri) to rinse cycle. 445 The Root of ambulatory care ..Avoid use of vasodilators (caffeine, alcohol, spices, hot water) and excessive sweating. ..Avoid use of provocative topical medications, such as corticosteroids for prolonged periods (risk of skin atrophy) and topical anesthetics and antihistamines (may sensitize exposed skin and increase risk of allergic contact dermatitis). ..Prevent complications of scratching by keeping fingernails short and clean, and by rubbing skin with the palms of the hands if urge to scratch is irresistible. Fig 1. Algorithm for the evaluation of pruritus Skin lesions Is the dermatitis typical for benign disease Treat underlying disease Treat underlying disease Symptomatic treatment as needed Was the trial effective Two-week trial of disease independent pruritus management Limited Iaboratory testing LFT/RFT/FBS/TFT/CBC with differential(ferritin)/Stool for OB, ova, parasite/Chest X ray Is testing diagnostic Acute onset of pruritus over several days Localized pruritus Pruritus limited to exposed skin Pruritus in other household members Recent travel Possible occupational exposure Review does not suggest systemic cause Diagnostic testing Skin scrapings(potassium hydroxide preparation mineral oil smear, Tzanck test): dermatophytes or scabies mites Skin biopsy(hematoxylin & eosin statin, direct immunofluorescence): mastocytosis, mycosis fungoides, bullous pemphigoid Skin cutrure: bacterial, viral, fungal infection No Yes No Yes Yes Yes Yes No No No Pruritus- Itching -Pharmacologic 1. Topical antihistamines ..Lucepin.. cream qid for 7days 2. Topical steroids ..Dermatop.. cream, oint, sol bid ..Bosong.. cream bid ..Tricot.. 0.1% cream bid 3. Systemic antihistamines ..Ucerax.. 25mg 1/2T-1T tid ..Clarityne.. 10mg qd ..Allegra.. 180mg 1T qd 4. Systemic corticosteroids ..Solondo.. 5mg 1T-12T#1-4 광범위한 피부질환시 고려 5. Anti-psychotics ..Doxecan.. 10mg 1C, 1-2C tid 정신적인 요인이 있을때 정신치료와 함께 항히스타민 효과가 있는 상기약제 투약 가능 ..Lucepin.. - Doxepin ..Dermatop.. - topical steroid제제로 prednicabate 0.25% ..Bosong.. - Prednisolone valerate0.3% cream ..Tricot.. - Triamcinolone acetonide 0.1% ..Ucerax.. - Hydroxyzine HCL 1st ..Clarityne.. - Loratadine 2nd ..Allegra.. - Fexofenadine ..Doxecan.. - Doxepin Specific management of Pruritic conditions Cholestasis Cholestyramine : 4 to 6 g orally 30 minutes before meals Ursodiol acid : 13 to 15 mg per kg per day orally Ondansetron : 4 to 8 mg IV, then 4 mg orally every eight hours 447 The Root of ambulatory care Opiate receptor antagonist such as nalmefene : 20 mg orally two times per day Rifampin : 300 mg orally twice daily Bile duct stenting for extrahepatic cholestasis Bright-light therapy Neurotic excoriation Pimozide : orally for delusions of parasitosis Selective serotonin reuptake inhibitor Notalgia paresthetica Capsaicin 0.025% cream applied to localized areas four to six times daily for several weeks Polycythemia vera Aspirin : 500 mg orally every eight to 24 hours Paroxetine : 10 to 20 mg orally per day Interferon alfa : 3 to 35 million IU per week Spinal opioid-induced pruritus Ondansetron : 8 mg IV, concurrent with opioid Nalbuphine : 5 mg IV, concurrent with opioid Uremia Ultraviolet B phototherapy two times per week for one month Activated charcoal, 6 g per day orally Capsaicin 0.025% cream applied to localized areas four to six times daily for several weeks 참고 문헌 Terry S. Ruhl : Itching,in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 1186-1187 김대현 : 소양증, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1051-1054 Louis J. Rusin, M.D. : Pruritis(Itching), in Conn's Current Therapy 2004, Robert E. Rakel(ed), Edward T. Bope(ed). Philadelphia, Saunders, 2004, P 37-39 Scott Moses, M.D. : Pruritus.A journal of the American Family Physicains 2003 ; 68 : 1135-1142, 1145-1146