Pearls for Monitoring and Managing Itch:  An Expert Panel 

A three-person panel covered the topic of itch recently at The Dermatology Education Foundation’s DEF Essential Resource Meeting 2024 (DERM2024) NP/PA CME Conference in Las Vegas, Nevada, with David Cohen, MD, MPH, leading “How to Avoid Doctor Strange: Pearls for Monitoring and Managing Itch.” Dr. Cohen was joined by Wendy Cantrell, DNP, CRNP, and Kara Gooding, MMS, PA-C. Following is a transcription of their discussion, edited with participant approval for clarity and length. 

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Dr. David Cohen: An itchy patient coming to the office might be very obvious and very easy. However, if no clear rash is present, it can be one of the most vexing and concerning patients that ever walk into the office, short of someone coming in denuded from TEN or a bad blistering disease. Itch has a terrible impact on patients’ quality of life. At-risk populations such as the elderly and darker-skinned patients present variably. Grover’s disease patients have 400 little red dots on their trunk and barely know they’re there or that it’s itchy, but then you have some with eight dots and the itching is driving them crazy. The severity of the skin disease does not always dictate the predictability of itch. 

We will talk about blood tests such as complete blood count (CBC) with differential other tests that you might do. The most important thing is that if a patient has an itch of unknown origin, with no clear eczema or itchy dermatosis, and they have been itching for fewer than 12 months, you really need to initiate a workup to figure out what’s going on because their skin probably isn’t the primary problem causing it. You can be the true hero in this situation when you discover an early malignancy or an early systemic disease. When you see eosinophilia, of course, you need to think of allergic phenomena, drug eruptions, fungal diseases, or parasites in the gastrointestinal tract. 

WHAT ARE YOUR MOST CONCERNING ISSUES, AND WHAT KIND OF BLOOD TESTS ARE YOU PERFORMING? 

Kara Gooding: Like Dr. Cohen said, when patients come in with itch without a primary rash, I tell them this is one of the most difficult things that we encounter in our practice. For baseline screening, we start with some simple tests, but we may eventually need to do a deeper dive and order some additional tests. I always call it the “alphabet soup”: We start with a CBC, a CMP, a TSH, and a UA, and sometimes I’ll add an ANA and a chest X-ray. For elderly patients, who very frequently have itch without a rash, I sometimes immediately order BP180 and BP230 tests to check for non-bullous pemphigoid. Besides that, making sure patients are up to date on their age-appropriate screenings including mammograms and colonoscopies as well as primary care visits is important. 

Cantrell: Biopsy is hard in this kind of condition because it may not give us the information that we need. If I decide to biopsy a patient like this, I tell them it may not give us much information. They can’t become frustrated with the process. Even no information is good information to have. And sometimes it does give us what we need. Sometimes it gives us a cutaneous T-cell lymphoma (CTCL) diagnosis. So, I don’t biopsy everyone, but I do it frequently, especially with recalcitrant patients. 

Dr. Cohen: This discussion can go two different ways. The itchy eczema patient, the unusual itchy psoriasis patient, and the lichen planus patient with drug eruption make you feel comfortable when they’re complaining of itch because it’s part of the disease process. The itchy patients who are out of proportion to what you suspect are different. But we’re going to cross the lines between the two throughout this discussion. 

Pruritus is incredibly common. It’s not a disease; it’s a symptom. I tell patients who do not have an obvious dermatosis: “Your body is trying to tell us something and I am trying to speak its language, so we’re going to do this workup. The reason I’m doing a chest X-ray is to see if anything is going on in your lungs or if there are any enlarged lymph nodes.” 

Itching is common. It impacts quality of life, mood, and psychosocial conditions, such as anxiety and depression. With age, some of the obvious things like dry skin neuropathies and even psychological issues will have an impact. Itch in pregnant patients is more of an emergent thing; if they’re starting to get itchy, you need to act on that quickly. Even if you see some excoriations, you cannot give triamcinolone to those patients. They need to go back to the OBGYN and get a full workup for cholestasis. We will go into that in further detail. 

It is valuable to use an itch assessment tool and document the results. We do it with every patient who might have an itchy dermatosis. With any inflammatory disease, we ask a patient to rate their itch on a scale of zero to 10, with 10 being the worst itch you might imagine and zero being no itch. Of course, some patients directly give you a number and some patients give you a 5-minute story without ever using a numeral. But it is important to ask those patients to provide a number for where they are now. The next question, then, is on the same scale: What is the worst itch you felt in the last 24 hours, from zero to 10? They might say, “Well, last week it was at 11.” Eleven was not a choice, and the question was about last night. But corralling everyone into this is the fun part. The process is incredibly valuable. It’s a documented, effective, and reliable tool and it will give you good information. Do you use this tool, and if so, how frequently? 

Cantrell: We do it with every dermatitis patient. This is now part of MIPS (Medicare’s Merit-based Incentive Payment System), so itch is critical to our success in documentation. My medical assistants do it for me. I often discuss the itch assessment tool with the patient as well, so MIPS is not the only reason for doing it, but MIPS is a big part of our reimbursement strategy. 

Gooding: We actually have it on an intake form so patients complete it even before they see my medical assistant, and then my medical assistants ask them again. I love it as an assessment tool when you can look back at a patient’s chart during their follow-up visit and say, “Your NRS score last time was an eight and now you’re a two.” They might say they don’t feel much better, but their assessment says the itch is significantly better. 

Dr. Cohen: Never discuss the last itch score that they gave you until you get the new itch score, because they will anchor it. It’s classically unreliable in younger children. Kids who have had lifelong eczema give very low numerical rating scores for itch. I just saw a patient who was 6 or 7 years old, and she was covered in eczema, but she gave me itch scores of three and four. She looks like she’s a nine, but that’s all she knows. How does she know anything but itching? Also, when you cross diseases, it’s not very reliable. In clinical trials for eczema, itch scores on moderate to severe disease are generally between seven and eight. But the itch scores in psoriasis trials are between six and seven. There is no way that a moderate-to-severe psoriasis patient is one point away from a moderate-to-severe eczema patient. That severe eczema patient doesn’t sit still in your office and the psoriasis patient is looking pretty good. If someone gives you an eight, nine, or 10, they are grabbing you by your white coat and shaking you to do something. You don’t take an eight, nine, or 10 and just say, “We’ll do these blood tests and see it in a couple of weeks.” You need to initiate something and address the itch with them. 

Again, you can use the variable itch scores. I like the numeric rating scale (NRS). There are visual analog scales for which people can point to very unhappy faces and very happy faces. Get the history down. How long has this been going on? Is there any history? Ask about all the atopic diseases and any other diseases that may be of consequence. Of course, if you are suspicious and if there’s no rash, ask about fever, night sweats, chills, and weight loss. If you practice for long enough, you will pick up Hodgkin’s disease in patients in their 20s who present to you with itching. You will find patients in their 50s, 60s, and 70s with myelodysplastic syndrome or polycythemia with aquagenic urticaria. You just need to listen for it and not look at secondary scratches. But I like seeing some of these things because I know I can explain their itch. These are a little bit more tolerable, but there’s a lot here to unpack. You use the Hanifin criteria as effectively as possible. You use medical history and family history to guide you. I had a patient with a very itchy forehead patch. She had a rash. Someone thought she had contact dermatitis, but she could not sleep; she had an NRS of three and a 24-hour worst NRS of eight. I patch tested her, and she had a number of issues, so I decided to start her on dupilumab. Now, she’s reporting a 95% improvement, yet her NRS scores went to one and five to six. That’s the impact that a three-point change in itch score meant to her because she can sleep; before, she couldn’t sleep. Documenting this note is so easy and it passes all of my reviews by external sources. 

Cantrell: You’re right that you cannot rule out malignancy. I recognized what was eventually diagnosed as non- Hodgkin’s lymphoma in a patient who was approximately 20 years old. He was having such terrible itch and could not get relief with basic care. Those are the types of things in your career that you never forget, because of the potential consequences if you had missed it. CTCL is another—perhaps a patient is in the early patch stage and just beginning to have itch. Those are two things I have seen that are always in the back of my mind when somebody comes in and is just saying, “I am just dying of itch.”