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Pruritus: Etiology and patient evaluation

Sara B Fazio, MD
Gil Yosipovitch, MD
Section Editors
Robert P Dellavalle, MD, PhD, MSPH
Jeffrey Callen, MD, FACP, FAAD
Deputy Editor
Abena O Ofori, MD


Pruritus (itch) is a common symptom, rather than a specific disease entity, that occurs in a diverse range of skin diseases and may appear as a prominent feature of extracutaneous disorders such as systemic, neurologic, and psychiatric diseases (table 1).

The pathogenesis and etiology of pruritus, as well as the evaluation of the patient with pruritus, will be reviewed here. The treatment of pruritus is discussed separately. (See "Pruritus: Overview of management".)


Pruritus is a common symptom that is experienced by all human beings at some point during the course of life. The frequent occurrence of pruritus is supported by the results of epidemiologic studies. In a large cross-sectional study (n = 11,730), chronic pruritus (pruritus persisting for more than six weeks) was reported in approximately 16 percent of German workers [1]. A separate study of almost 19,000 adults in Norway found that the prevalence of pruritus in the general population was approximately 8 percent [2].


Although the neurologic pathways that lead to itch are not fully understood, it is generally accepted that transmission of signals along unmyelinated, histamine-sensitive, and nonhistamine-sensitive peripheral C-nerve fibers (distinct from the C-nerve fibers that transmit pain) is involved. These fibers represent a minority (up to 5 percent) of C-nerve fibers in the body and are characterized by a slow conduction velocity and extensive terminal branching [3-8]. Histamine-sensitive fibers have an important role in transmission of acute itch and itch in urticaria, while nonhistamine nerve fibers have a significant role in itch transmission of most types of chronic itch, possibly accounting for the poor response of many types of chronic itch to oral antihistamines.

Signal transmission in nerves may be stimulated by the action of a variety of neural mediators on sensory nerve endings in the epidermis, dermal-epidermal junction, and other sites. Mediators that have been identified as potential peripheral or central contributors to pruritus include histamine, proteases, cathepsins, gastrin releasing peptide, opioids, substance P, nerve growth factor, interleukins, and prostaglandins and their respective receptors [9-11]. Of these, the identification of Mas-related G protein-coupled receptors (an itch-specific population of neurons) represents a major advance in understanding chronic itch. These receptors are key for transmission of nonhistaminergic itch [12].

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Literature review current through: Nov 2017. | This topic last updated: Sep 23, 2016.
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