Senile Pruritis (SP) - An Emerging Geriatric Public Health Problem (EGPHP)!

Introduction

Senile pruritus can be defined as a chronic pruritus of unknown origin in elderly people. in persons over 65 years old. It is one of the most common conditions in the elderly accompanied by changes in temperature and textural characteristics of the skin. In the elderly, xerosis is the most common cause for an itch due to the degradation of the skin barrier over time [1]. Diabetes, Liver or kidney disease, Eczema, Psoriasis, Cholestasis, Obsessive-compulsive disorder, and Allergies are other causes. The whole-body itch might be a symptom of an underlying illness, like liver disease, kidney disease, anemia, diabetes, thyroid problems, and certain cancers [2].

Multiple studies have reported a prevalence of 11–78% pruritus in elderly patients [2]. The etiology of pruritus in elderly is not fully understood. In most elderly people, occasional pruritis is due to climate or allergens, but when it turns into long standing problem, it can induce debilitating effects, like irritation, sleep impairment, resulting in clinical depression, to the extent that they would prefer a shorter life free of symptoms than a longer life with pruritus. In fact, while an acute pruritus is the commonest cause making people rush for consultation to seek relief and chronic itch makes the sufferer avoid any social group.

Itch is clinically classified into seven types: i) Itch caused by systemic diseases, like Thyroid diseases, Polycythemia vera, Iron deficiency anemia, ii) itch caused by skin diseases, Xerosis, irritant or allergic dermatitis, Atopic dermatitis, Psoriasis, Urticaria, & Seborrheic dermatitis iii) neuropathic pruritus, Brachioradial pruritus - triggered by UV light, Brachioradialis muscle (C6 dermatome) Notalgia paranesthesia iv) Psychogenic pruritus, Somatoform disorders, dissociative disorders, schizophrenia, Hallucinations, delusional parasitosis and Adjustment disorder v) Drug-induced pruritus, with or without rashes, vi) pruritus with multiple factors, and vii) pruritis of unknown causes- without a primary rash in the absence of xerosis or other recognizable causes [3].

Pathophysiology: Various neuronal mediators, signaling mechanisms at neuronal terminals, central and peripheral neurotransmission pathways, and neuronal sensitizations processes cause itching. A variety of therapies are used, and several novel drugs are being developed to relieve itch, including systemic and topical treatments [4].

Basic Management includes symptomatic management with antihistamines and topical applications, sometime adding cortisones. Of late use of Gabapentin has resolved the issue though the mechanism is not yet clear.

This article is based on 3 different cases managed or observed being managed by the author in last 2 years.

Discussions

Identifying the underlying causes of chronic pruritus tends to be more difficult in older patients, regardless of the apparent time between the onset of symptoms and the onset of possible causes. Diagnosing Pruritus:

History Taking: “To diagnose pruritus in the elderly primary care physician must take a complete history of the itch and other medical comorbidities and the medications used to treat them. Followed by a complete skin exam, paying attention to the ‘primary’ skin lesion. If a rash is present, a skin biopsy is usually performed to help confirm the diagnosis.” One of the diagnostic challenges associated with pruritus in older adults is the difficulty of examining geriatric skin. As the skin of older patients is often “busy” due to skin changes from lifelong sun exposure and other benign skin growths. “In addition, the immune alterations of age may modify the appearance of typical skin. For example, scabies may not itch, may involve the face, and may spare the finger webs, all very atypical features for scabies in a younger patient. Laboratory and radiological evaluation may be required to exclude iron deficiency, renal disease, liver disease, diabetic neuropathy, and lymphoma as possible causes. “A careful medicine history, especially for exposure to calcium channel blockers, may identify a medication as the cause of the pruritus. Diagnosing pruritus is time consuming. The care provider must talk to the patient directly, as the representative may not give correct picture as happened to me in case of Venkamma, whose son said that itch is on the back and attributed it to long hours of sleeping supine. When checked with her directly it all over body, more see behind ears and scalp.

Physical Examination: As part of the initial diagnosis, identifying pruritic skin disease usually involves a thorough examination of a patient’s skin and detailed questions about their medical histories. It’s important to look for dry, red, rough, scaly, or bumpy skin. Additionally, it’s necessary to ask patients whether they know what inciting factor caused the pruritus and whether they’ve found anything that alleviates the itch. Lab tests (blood, thyroid, liver, and kidney function tests) may be needed to rule out other causes. “In refractory cases, radiological evaluation, and routine cancer screenings up to date (e.g., colonoscopy, mammography) may be necessary. Bullous pemphigoid is present in older adults with pruritus and nonspecific skin eruptions without blisters, so special ELISA [enzyme-linked immunoassay] testing and immunofluorescent skin biopsy testing may also be required to make this diagnosis. “The examination must also look for possible secondary causes. Organomegaly (liver, spleen), and Lymph nodes palpation, in rare cases of lymphoma with pruritus are assessed.

Investigations: Asking for a full blood count, renal, liver, fasting glucose and thyroid function studies is done in the first instance. A full blood count is helpful in assessing hematological disorders such as leukemias, anemia and polycythemia. Renal and liver function studies evaluate renal or hepatic dysfunction. Abnormalities in liver function could also point to infections, or drug-related, alcoholic, or inflammatory hepatitis. Given the association of itch with neoplasms, patients must get an age-appropriate cancer screening [5] (Figure 1).

Dry aging skin, xerosis, is the commonest cause of itch in elderly patients, with a prevalence ranging from 38 to 85%. Multiple skin changes the alterations in the barrier function of the stratum corneum (SC), and proteases, pH variations, and decreased activity of sebaceous and sweat glands in the elderly are related to xerosis and chronic pruritus. The SC is a barrier to prevent trans-epidermal water loss and provides protection from external factors. The SC constantly undergoes cellular turnover, and as it ages, the normal process of desquamation can be altered, leading to the appearance of dry skin [2].

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Considering multiple drugs being taken that might contribute to pruritus by inducing side effects or drug associated eczematous skin lesions is the priority. A detailed patient history and laboratory tests may be required for accurate diagnosis. For chronic pruritus of inflamed or excoriated skin lesions, a skin biopsy for histological or immunofluorescence testing may be required.

An observational study, of 300 patients aged 60 years and above for geriatric dermatoses, involving 211 patients attending dermatology OPD (group A) and 89 patients were controls (Group B) from other were selected from specialties. Detailed history, thorough examination and appropriate investigations were done after obtaining informed consent. Results indicated that among 300 study subjects, 192 (64%) were, males were and 108 (36%) were females. The majority were in the 60 -70 years age group (82%). Primary ageing dermatoses were more prevalent than non-ageing dermatoses (95.3%). Pruritus was the most common complaint (164, 54.7%). Common patterns of geriatric dermatoses were wrinkling (286, 95.3%), xerosis (164,54.7%), seborrheic keratosis (94, 31.3%), Leucoplakia (48,16%), actinic keratosis (6,2.3%), infections (66, 22%), eczema (48, 16%), pigmentary disorders (38,12.7%), Papulo-squamous disorders (31, 10.3%), autoimmune blistering disorders (6,2%) and exfoliative dermatitis in 5 (1.7%). Geriatric dermatoses become more prevalent following environmental and occupational hazards as their skin is nutritionally, immunologically, and psychologically compromised. Primary ageing and pathological disorders were higher among pre-existing dermatoses group than other systemic disorders group. Early recognition of patterns and appropriate management improve the quality of life in elderly [3, 5].

A meta-analysis of 46 relevant articles, Indian recommendation for an effective diagnosis of pruritus includes a comprehensive patient history and physical examination for determining whether pruritus is due to a dermatologic disorder or an underlying systemic disease. General care measures like topical therapies with local anesthetics, pramoxine, capsaicin, calcineurin inhibitors, menthol, camphor, zinc, doxepin, corticosteroids, and palmitoyl-ethanolamine. This could be followed by basic investigations and subsequent suitable therapies. The systemic therapies, with oral antihistamines (e.g. hydroxyzine, Foristal Lontab, Allegra 24 hrs. etc.) are the first line of treatment for pruritus. The other systemic therapies include gabapentin and pregabalin, tricyclic antidepressants, doxepin, mirtazapine, naltrexone, cyclosporine and ultraviolet (UV) phototherapy [5].

While xerosis (dry skin) must be ruled out first, one- third of the geriatric population suffers from Seborrheic dermatitis (SD), which is associated with localized itch, and skin manifestation are characterized by overlying adherent, greasy scales. SD predominantly affects oily areas of the body, such as the scalp, periauricular area, nasolabial folds, cheeks, sternal area and interscapular areas and may also affect other body folds. Other dermatological conditions associated to chronic itch in the elderly are atopic dermatitis, Psoriasis, and Urticaria. Nummular eczema (NE) is an extremely pruritic, inflammatory skin disease found in elderly patients and is considered as a late-onset form of atopic dermatitis. Severe scratching or rubbing to eliminate the itch will result in skin damage, such as scratches, abrasions, erythema, lichenification, ulcers, and pigmentation of the skin. Skin diseases that induce itch mainly include eczematous dermatitis, hives, food allergies, insect bites, and scabies.

Cutaneous Immunologic Reactions: The transformation of the immune system results from the process of aging, known as immunosenescence (IS), is related to chronic pruritus. It affects both innate and adaptive immunity and induces increased autoreactivity. Bullous pemphigoid (BP), more common in the elderly, may manifest with pruritus and a nonspecific urticarial rash accompanied by circulating autoantibodies. Elderly patients suffering from chronic idiopathic pruritus produced evidence of immune dysregulation, such as lymphopenia, eosinophilia, and hypo-gammaglobulinemia. With the progression of IS, the protective effects of T helper 1 cells diminish, causing higher influence of T helper 2 cell–driven allergic reactions. This immunological imbalance increases the susceptibility of older people to chronic pruritus. In addition, Langerhans cells found in the skin of elderly tend to decrease dendrites as well as decreased numbers.

If an itching sensation occurs on the skin due to systemic diseases, then kidney disease, liver disease, gastrointestinal disease, or cancer could be the problem. Additional comprehensive laboratory tests are needed to rule out associated systemic disorders such as diabetes, renal dysfunction, and hepatic or hematologic disorders. In chronic renal failure, itch tends to become more pronounced when hemodialysis is done later than when is done earlier. Itch may also accompany various obstructive biliary diseases (primary biliary sclerosis, cirrhosis, etc.) in which bile ducts are blocked. If pruritus is less than 1 year, radiological and laboratory tests are necessary to rule out malignant disease. In patients with Hodgkin’s disease (a malignant hematological tumor), itch may appear months earlier than other systemic symptoms. Itch may also occur in association with intestinal parasites, hyper- or hypothyroidism, diabetes, and acquired immunodeficiency. In addition, medication used in patients with systemic diseases may cause allergic reactions and itch with skin rashes.

As dry skin is a common problem in Indian population and a cause for pruritus’ emollients that coat the skin with lipids can reduce the damage to skin barrier and reduce itch. Adding topical anesthetics such as pramoxine to commercial emollients to further reduce the itch. Western (USA, UK, Russia) experience document that, chronic pruritus an itch lasting more than six weeks experienced by people 65 years old and older. “It’s common, with a prevalence of 25% to 40%” [1, 6].

Scratching the itchy areas can cause the inflamed skin cells and nerve endings to release chemical mediators such as proteases that induce itch. While physical discomfort can be extremely irritating on its own, pruritus leads to the experience of sleep disruption, depression, and anxiety due to the overwhelming frustration of not being able to eradicate the itchy sensation. According to many senior dermatologists in Bengaluru “pruritic skin disease is an ever-increasing concern in the elderly population.” In many cases like our case reports the patients will have no notable skin rash. The skin conditions like dry skin, stasis dermatitis on the lower legs and above the ankles (due to venous insufficiency), age-associated immunosenescence and in diseases such as bullous pemphigoid an autoimmune blistering disease that’s more common in people older than 70 years. Senescence of the nervous system and subclinical neuropathy which occurs in diabetes can cause itch. The itch in diabetes may precede the abnormalities of blood sugar prediabetic neuropathy.

Management: There are two steps in managing pruritic skin disease, academically i) First identify and treat the underlying cause ii then treat the itching. But in Practice First treat the itching, and then make all out efforts and treat the underlying cause. Often the cause may not be identified. Therefore, in the case of xerosis, patients must be advised moisturizers are recommended for pruritic patients by applying emollients liberally. Most Indian patients have done this before coming to a health care provider. These are most effective after showering a practice most Indians reverse. Patients must be encouraged to avoid the use of drying soaps and instead use mild cleansers or Bengal gram powder. Modulating water temperature and avoiding extreme high temperatures while bathing is another simple intervention. A cold compress, ice cubes, or cooling agents containing menthol & camphor help relieve pruritus (Figure 2).

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Systemic Antihistaminic or Chlorpromazine (25-50 mg based on body weight) tablets orally before going to bed, and local antipruritic lotions containing Crotamiton (Crotorax) twice a day would give relief as was our both cases response.

Sometimes first-generation antihistamines may increase the risk for falling and mental decline and, therefore, need to be monitored in this population and dose adjusted. Our experience is that these are not a big problem in Indian population especially women as they are mostly sleeping or sitting in one place hardly mobile except for going to ease themselves. Caution is needed in choosing an appropriate antipruritic cocktail for an elderly patient as most pruritus is mediated by nonhistaminergic sensory neurons. These ‘itch-specific’ nerves do not have histamine receptors, so antihistamines are generally ineffective for pruritus in the elderly.” Alternatives include gabapentin and pregabalin in doses like managing pain and neuropathies. Low-dose Sinequan (up to 6 mg), and tetrahydrocannabinol (THC, Marinol) are helpful. Ultraviolet phototherapy can be an effective treatment for pruritus in the elderly and avoids possible systemic complications. Given the limited number of treatment options, it is critical to continue to try and treat any underlying skin or systemic condition that may be contributing to the pruritus.” Of course, the treatment must be directed at the underlying cause when present.

Treating any underlying cause such as iron deficiency or renal or liver disease may be all that’s required. For the most severely pruritic patients, dry skin is usually not the cause of their pruritus. Most inflammatory dermatosis require targeted treatment, through immunosuppressives like methotrexate or mycophenolate.” “Systemic therapies include antihistamines or doxepin. Narrow-band UVB [type B ultraviolet] phototherapy may also be helpful. If an underlying systemic cause is detected, treatment is often specific to the systemic disease. Since xerosis is particularly common in elderly patients, strategies directed at treating xerosis are often fruitful as first-line attempts.” A cream with hydrocortisone, typically applied locally two times a day for two weeks. If hydrocortisone doesn’t help, trying an anti-itch cream with Pramoxine hydrochloride is also advocated [6].

Side effects of treatment of pruritus in older adults need to be constantly monitored, as they are more susceptible to the sedative effects of antihistamines, GABAergic drugs, and antidepressants certain medications, target the neural system, and may lead to confusion, therefore, be used cautiously and slowly withdrawn as soon as possible [7].

Conclusion

Itching in any part of the body without a primary rash and in the absence of xerosis or other recognizable causes in a person over 65 years old is called Senile Pruritis. Though Pruritus is a relatively common symptom everybody experiences at any point in their life, it impacts quality of life among elderly population.

Dry skin is a common problem in Indian population and a cause for pruritus, xerosis must be ruled out first. Next comes Seborrheic dermatitis (SD), which is associated with localized itch, and skin manifestation are characterized by overlying adherent, greasy scales. SD predominantly affects oily areas of the body, such as the scalp, periauricular area, nasolabial folds, cheeks, sternal area and interscapular areas and may also affect other body folds. Then comes the Psychogenic pruritus, somatoform disorders, dissociative disorders, schizophrenia, Hallucinations, delusional Parasitosis and Adjustment disorder followed by Nummular eczema (NE) is an extremely pruritic, inflammatory skin disease found in elderly patients and is considered as a late- onset form of atopic dermatitis.

Idiopathic generalized pruritus is a diagnosis of exclusion and is often difficult for primary health care providers to treat. However, they can try: i) Standard treatment with antihistamines, local application of antihistamines of Crotamiton 10% lotion on affected area twice a day after bathing. If sleep is disturbed a short-term Chlorpromazine (25 mg) be given. ii) A cream with hydrocortisone, applied locally two times a day for two weeks. If hydrocortisone also doesn’t help, an anti-itch cream with Pramoxine hydrochloride is tried. iii) with patients who present with uncontrolled idiopathic pruritus, a trial of low-dose gabapentin must be considered. iv) Empathetic support from the family contributes to medical management.