Ask the Pharmacist

Q) Lately, I have been constantly itchy all over; Why is this happening and what can I do about it?

A) At any point in the year, but more so in the winter months, itchy skin is easily one of the most common complaints dealt with in any community pharmacy. Itch, or pruritis as its known to healthcare practitioners, is a skin sensation that is quite similar in many respects to pain. This is because both sensations use many of the same nerve fibers to transmit their signals to the brain. It is therefore not surprising that there are a few medications that we will discuss later that can work quite effectively on either complaint.

An itch can be defined as localized or generalized. When it is localized that means it is felt in one (or possible more) area of the body. Getting to the answer as to what is causing this type of itch is generally far easier than figuring out what is behind a generalized itch, which is an itch that is essentially felt all over the body.

For localized itches, the cause is almost always related to a skin condition in that particular area of the body. For example if the itch is located on the scalp, your physician is likely to suspect psoriasis, lice or sebborheic dermatitis (also known as dandruff) and will treat each differently. If the pruritis is originating in the hands or feet, the diagnosis is likely to be contact dermatitis (i.e. an allergic reaction to something you touched), atopic dermatitis (probably better known as eczema), scabies, ringworm or pompholyx (characterized by small, itchy blisters that progress to scaly spots over several weeks). Localized itches are also far more likely to be associated with a rash or some other skin reaction which also aids in the diagnosis process.

When the itch sensation is felt literally everywhere, up to 50% of the time source of the problem is not really the skin, but is instead an untreated systemic disease that is producing an itch as one of its symptoms. That is why many physicians will order both a stool culture and blood work upon coming across a complaint such as this and may look at your red and white blood cell counts, your blood sugar and the function of such organs as the thyroid, liver and kidneys.

Some examples of systemic conditions that can lead to a feeling of generalized pruritis include:

· Allergies
· Liver disease, typically in later stages
· Iron deficiency
· Kidney disease, especially during dialysis
· A neuropathy (a degeneration of the nerve fibres)
· Thyroid disease, can occur when it is either too high or low
· Cancer, in particular leukemias and lymphomas
· Parasitic infections
· HIV especially soon after infection

Medications can also be a source of a generalized itch. It may be due to the active ingredient or to one of the many other chemicals that are involved in making a pill (such as a dye, a filler…). While any drug can cause an itch, some are more prone than others. These include the opioids/ narcotics, chemotherapeutic drugs and chloroquine (which can cause this in about 60-70% of black Africans who are prescribed it).

The itch may start within several hours of the first dose or up to several weeks later and may be either localized or generalized. Most drugs have several versions available on the market including an original version (brand name) and copies of it (generics) and the varying brands can use different additives. Therefore, if the drug has remained the same but the brand used has changed, the reaction might well be due to the use of a different additive in the new generic. Stopping the drug should make the itch go away but it may well persist for several days to months.

I should also note that a generalized itch can also be a sign of pregnancy or a mental health condition such as stress, high anxiety or obsessive compulsive disorder. The key to treatment is identifying the cause and treating the source of the problem. This is frequently far more difficult than it sounds and in some cases there are no abnormalities found after all the tests have come back negative.

There is a condition called Willan’s pruritis which is the name given to a generalized itch that tends to occur in seniors and is chalked up to yet another part of the ageing process. As we age our skin shows an altered sensory perception, a reduction in both fat and blood flow as well as a somewhat impaired immune response, all of which make it more prone to itching.

Regardless of whether a cause can be found, there are effective treatments and lifestyle choices that can safely reduce the irritation. As far as daily habits go, there are a number you can adapt including:

· Bathing should be limited to short showers preferably using water that is lukewarm at most and only a couple of times a week. If a bath is a must, put some mineral oil in it at the end or use one of the many commercial bath products for itchy skin such as the Aveeno line

· Only apply soap to the groin, armpits, anal area, under the breasts, and areas of oily skin. Use a less drying cleanser like Cetaphil for other areas.

· Apply a mild moisturizing cream immediately after bathing when you are just towel dry. Preferably an emollient type which work by forming an oily layer on top of the skin that traps the water in the skin. A good and relatively cheap example of this is Eucerin. These types of moisturizers tend to be very thick.

· Humidify your home to at least 40%, especially during dry, cold months.

· Avoid contact with wool, fiberglass, detergents, or other topical irritants.

· Poor sleep, smoking or an unhealthy diet can make the skin drier and more reactive to irritants.

· Do not scratch!! This is not an old wives tale. Scratching causes a sensation of pain which causes the body to make serotonin to counteract the pain. Serotonin subsequently activates what are called the GRPR neurons which then serve to make the itch sensation more intense.

On the pharmaceutical side, effective treatments often start with creams such as the corticosteroid ones (hydrocortisone can now be bought without a prescription) or anti-itch creams that use ingredients such as menthol that interfere with the transmission of the nerve signal to the brain. Over the counter oral antihistamines are also a safe bet but most dermatologists do not recommend the cream versions as they sometimes cause itchy skin reactions on their own. Reactine (cetirizine) or Aerius (desloratidine) tend to work better than their counterparts and there are a couple of other effective ones available with a prescription.

Other pills that can work very well include gabapentin and a number of the antidepressants since they work on serotonin which is involved in this whole process. Phototherapy, in which a person is exposed to ultraviolet light several times a week can also be a very effective remedy to this problem. An itch may seem like a small problem given the state of the world. And in most cases, it probably is. But over time it can really affect the quality of your life and sleep patterns and it may just be a sign of a very serious underlying condition that needs to be addressed as soon as is possible. For more information contact your pharmacist.