Localized pruritic dermatoses

Lichen Simplex Chronicus

Other common terms for lichen simplex chronicus include localized neurodermatitis and lichenified dermatitis. There are pros and cons for all the terms.

Lichen simplex chronicus (Fig 11-1 and Fig 11,-2) is a common skin condition characterized by the occurrence of single or, less frequently, multiple patches of chronic, itching, thickened, scaly, dry skin in one or more of several classic locations. It is unrelated to atopic eczema.

Lichen Simplex Chronicus Scrotum

Figure 11-1. Localized lichen simplex chronicus of the leg. This is a common location. Note the lichenification and the excoriations due to the marked pruritus. (K.U.M.C.; Duke Labs, Inc.)

Lichen Simplex Chronicus Scalp

Figure 11-2. Localized lichen simplex chronicus. (Top left) In occipital area of scalp. (Top right) Of scrotum, with marked lichenification and thickening of the skin. (Bottom left) Of medial aspect of ankle, following lichen planus of the area. ( Bottom right) On dorsum of foot. (Duke Labs, Inc.)

PRIMARY LESIONS. This disease begins as a small, localized, pruritic patch of dermatitis that might have been an insect bite, a chigger bite, contact dermatitis, or other minor irritation, which may or may not be remembered by the patient. Because of various etiologic factors mentioned, a cycle of itching, scratching, more itching, and more scratching supervenes, and the chronic dermatosis develops.

SECONDARY LESIONS. These include excoriations, lichenification, and, in severe cases, marked verrucous thickening of the skin, with pigmentary changes. In these severe cases, healing is bound to be followed by some scarring.

DISTRIBUTION. This condition is seen most commonly at the hairline of the nape of the neck and on the wrists, the ankles, the ears (see external. otitis), anal area (see pruritus . ani), and so on.

COURSE. The disease is quite chronic and recurrent. Most cases respond quickly to correct treatment, but some can last for years and defy all forms of therapy. SUBJECTIVE COMPLAINTS. Intense itching, often paroxysmal, usually worse at night, occurs even during sleep.

CAUSES. The initial cause (a bite, stasis dermatitis, contact dermatitis, seborrheic dermatitis, tinea cruris, psoriasis) may be very evanescent, but it is generally agreed that the chronicity of the lesion is due to the nervous habit of scratching. It is a rare patient who will not volunteer the information or admit, if questioned, that the itching is worse when he or she is upset, nervous, or tired. Why some people with a minor skin injury respond with the development of a lichenified patch of skin and others do not is possibly due to the personality of the patient.

AGE GROUP. It is very common to see localized neurodermatitis of the posterior neck in menopausal women. Other clinical types of neurodermatitis are seen in any age.

FAMILY INCIDENCE. This disorder is unrelated to allergies in patient or family, thus differing from atopic eczema. Atopic people are more "itchy," however. RELATED TO EMPLOYMENT. Recurrent exposure and contact to irritating agents at work can lead to lichen simplex chronicus. DIFFERENTIAL DIAGNOSIS

Psoriasis: Several patches on the body in classic areas of distribution; family history of disease; classic silvery whitish scales; sharply circumscribed patch (see Chap. 1.4).

Atopic eczema: Allergic history in patient or family; multiple lesions; classically seen in cubital and popliteal areas and face (see Chap, 9).

Contact dermatitis: Acute onset; contact history positive; usually red, vesicular, and oozing; distribution matches site of exposure of contactant; may be acute contact dermatitis overlying lichen simplex chronicus due to overzealous therapy (see Chap 9).

Lichen planus, hypertrophic form on anterior tibial area: Lichen planus in mouth and on other body areas; biopsy specimen usually characteristic (see Chap, 14).

Seborrheic dermatitis of scalp: Does not itch as much; is better in summer; a diffuse, scaly, greasy eruption (see Chap 13).

TREATMENT

A 45-year-old woman presents with a severely itching, scaly, red, lichenified patch on back of the neck at the hairline. First Visit

1. Explain the condition to the patient and tell her that your medicine will be directed toward stopping the itching. If this can be done, and if she will cooperate by keeping her hands off the area, the disease will disappear. Emphasize the effect of scratching by stating that if both arms were broken, the eruption would be gone when the casts were removed. However, this is not a recommended form of therapy.

2. For severe bouts of intractable itching, prescribe ice cold Burow's solution packs.

Sig: Add 1 packet of Domeboro powder to 1 quart of ice cold water. Apply cloth wet with this solution for 15 minutes p.r.n.

3. A moderate-potency corticosteroid ointment or emollient cream 15.0 Sig: Apply q.i.d., or more often, as itching requires.

The moderate-potency fluorinated corticosteroid creams (Synalar, Cordran, Lidex, Diprosone, Cutivate) can be used under an occlusive dressing of plastic wrap on lesions on an extremity. The dressing can be left on overnight.

Warning: Long-continued occlusive dressing therapy with corticosteroids can cause atrophy of the skin. SUBSEQUENT VISITS

1. Add menthol (0.25%) or coal tar solution (3% to 10%) to above ointment or cream for greater antipruritic effect.

2. Intralesional corticosteroid therapy. This is a very effective and safe treatment. The technique is as follows. Use a 1-inch long No. 26 needle or 30-1/2 needle and a Luer-Lok type syringe. Inject 5 or 10 mg of triamcinolone parenteral solution (Kenalog-10 or Aristocort Intralesional Suspension) intradermally or subcutaneously, directly under the skin lesion. An equal amount of saline should be mixed with the solution in the syringe. Do not inject all the solution in one area, but spread it around as you advance the needle. The injection can be repeated every 2 or 3 weeks as necessary to eliminate the patch of dermatitis. Warning: A complication of an atrophic depression at the injection site can occur. This usually can be avoided if the concentration of triamcinolone in one area is kept low, and when it occurs, it usually disappears after months.

RESISTANT CASES

1. A tranquilizer

2. Prednisone 10 mg

Sig: 1 tablet q.i.d. for 3 days, then 2 tablets every morning for 7 days.

3. Dome-Paste boot or Coban wrap. Apply in office for cases of neurodermatitis localized to arms and legs. This is a physical deterrent to scratching. Leave on for a week at a time.

4. Psychotherapy is of questionable value.

External Otitis

External otitis is a descriptive term for a common and persistent dermatitis of the ears due to several causes. The agent most frequently blamed for this condition is "fungus," but pathogenic fungi are rarely found in the external ear. The true causes of external otitis, in order of frequency, are as follows: seborrheic dermatitis, lichen simplex chronicus, contact dermatitis, atopic eczema, psoriasis, pseudomonas bacterial infection (which is usually secondary to other causes) and, lastly, fungal infection, which also can be primary or secondary to other factors. For further information on the specific processes, refer to each of the diseases mentioned.

TREATMENT

Treatment should be directed primarily toward the specific cause, such as care of the scalp for seborrheic cases or avoidance of jewelry for contact cases. When this is done, however, certain special techniques and medicines must be used in addition to clear up this troublesome area.

An elderly woman presents with an oozing, red, crusted, swollen left external ear, with a wet canal but an intact drum. A considerable amount of seborrheic dermatitis of the scalp is confluent with the acutely inflamed ear area. The patient has had itching ear trouble off and on for 10 years, but in the past month, it has become most severe.

First Visit

1. Always inspect the canal and the drum with an otoscope. If excessive wax and debris are present in the canal, or if the drum is involved in the process, the patient should be treated for these problems or referred to an ear specialist. An effective liquid to dry up the oozing canal is as follows:

Hydrocortisone powder 1%

Burow's solution, 1:10 strength q.s. 15.0

2. Burow's solution wet packs

Sig: Add 1 packet of Domeboro powder to 1 quart of cool water. Apply wet cloths to external ear for 15 minutes t.i.d.

3. Corticosteroid ointment 15.0 Sig: Apply locally to external ear t.i.d., not in canal.

sauer notes

1. Many cases of acute ear dermatitis are aggravated by an allergy to the therapeutic cream, such as Neosporin, or the ingredients in the base.

2. A corticosteroid in a petrolatum base eliminates this problem.

3. Use 1% Hytone ointment, DesOwen ointment, or Tridesilon ointment.

Several days later, after decreased swelling, cessation of oozing, and lessening of itching, institute the following changes in therapy:

1. Decrease the soaks to once a day.

2. Sulfur, ppt. Corticosteroid ointment q.s.

Sig: Apply locally t.i.d. to ear with the little finger, not down in the canal with a cotton-tipped applicator

For persistent cases, a short course of oral corticosteroid or antibiotic therapy often removes the "fire" so that local remedies will be effective. Pruritus Ani

Itching of the anal area is a common malady that can vary in severity from mild to marked. The patient with this very annoying symptom is apt to resort to self-treatment and therefore delay the visit to the physician. Usually, the patient has overtreated the sensitive area, and the immediate problem of the physician is to quiet the acute contact dermatitis. The original cause of the pruritus ani is often difficult to ascertain.

PRIMARY LESIONS. These can range from slight redness confined to a very small area to an extensive contact dermatitis with redness, vesicles, and oozing of the entire buttock.

SECONDARY LESIONS. Excoriations from the intense itching are very common, and after a prolonged time, they progress toward lichenification. A generalized papulovesicular id eruption can develop from an acute flare-up of this entity.

COURSE. Most cases of pruritus ani respond rapidly and completely to proper management, especially if the cause can be ascertained and eliminated. Every

physician, however, will have a patient who will continue to scratch and defy all therapy.

CAUSES. The proper management of this socially unacceptable form of pruritus consists in searching for and eliminating the several factors that contribute to the persistence of this symptom complex. These factors can be divided into general and specific etiologic factors.

General Factors

Diet: The following irritating foods should be removed from the diet: chocolate, nuts, cheese, and spicy foods. Coffee, because of its stimulating effect on any form of itching, should be limited to 1 cup a day. Rarely, certain other foods are noted by the patient to aggravate the pruritus.

Bathing: Many patients have the misconception that the itching is due to uncleanliness. Therefore, they resort to excessive bathing and scrubbing of the anal area. This is harmful and irritating and must be stopped.

Toilet care: Harsh toilet paper contributes greatly to the continuance of this condition. Cotton or a proprietary cleansing cloth (Tucks) must be used for wiping. Mineral oil or Balneol lotion can be added to the cotton if necessary. Rarely, an allergy to the pastel tint in colored toilet tissues is a factor causing the pruritus.

Scratching: As with all the diseases of this group, chronic scratching leads to a vicious cycle. The chief aim of the physician is to give relief from this itching, but a gentle admonishment to the patient to keep hands off is indicated. With the physician's help, the itch-and-scratch habit can be broken. The emotional and mental personality of the patient regulates the effectiveness of this suggestion.

SPECIFIC ETIOLOGIC FACTORS

Oral antibiotics: Pruritus ani from oral antibiotic therapy is seen frequently. It may or may not be due to an overgrowth of candidal organisms. The physician who automatically questions patients about recent drug ingestion will not miss this diagnosis.

Lichen simplex chronicus: It is always a problem to know which comes first, the itching or the "nervousness." In most instances, the itching comes first, but there is no denying that once pruritus ani has developed, it is aggravated by emotional tensions and "nerves." However, only the rare patient has a "deep-seated" psychological problem.

Psoriasis: In this area, psoriasis is common. Usually, other skin surfaces are also involved.

Atopic eczema: Atopic eczema of this site in adults is rather unusual. A history of atopy in the patient or family is helpful in establishing this cause.

Fungal infection: Contrary to old beliefs, this cause is quite rare. Clinically, a raised, sharp, papulovesicular border is seen that commonly is confluent with tinea of the crural area. If a scraping or a culture reveals fungi, then local or systemic antifungal therapy is indicated for cure.

Worm infestation: In children, pinworms can usually be implicated. A diagnosis is made by finding eggs on morning anal smears or by seeing the small white worms when the child is sleeping. Worms are a rare cause of adult pruritus ani.

Hemorrhoids: In the lay person's mind, this is undoubtedly the most common cause. Actually, it is an unimportant primary factor but may be a contributing factor. Hemorrhoidectomy alone is rarely successful as a cure for pruritus ani.

Cancer: This is a very rare cause of anal itching, but a rectal or proctoscopic examination may be indicated. TREATMENT

A patient states that he has had anal itching for 4 months. It followed a 5-day course of an antibiotic for the "flu." Many local remedies have been used; the latest, a supposed remedy for athlete's foot, aggravated the condition. Examination reveals an oozing, macerated, red area around the anus.

First Visit

1. Initial therapy should include removal of the general factors listed under Causes and giving instructions as to diet, bathing, toilet care, and scratching.

2. Burow's solution wet packs

Sig: Add 1 packet of Domeboro to 1 quart of cool water. Apply wet cloths to the area b.i.d. while lying in bed for 20 minutes, or more often if necessary for severe itching. Ice cubes may be added to the solution for more antiitching effect.

3. Low-potency corticosteroid cream or ointment q.s. 15.0 Sig: Apply to area b.i.d.

4. Benadryl, 50 mg

Sig: 1 capsule h.s. (for itching and sedation). Comment: Available over the counter

sauer notes

1. Do not prescribe a fluorinated corticosteroid salve for the anogenital area. It can cause telangiectasia and atrophy of the skin after long-term use.

2. One of my favorite medications for pruritus ani or genital pruritus is 1% Hytone ointment applied sparingly locally two or three times a day. The petrolatum base is well tolerated.

3. If the anogenital pruritus is resistant to therapy and especially if the involvement is unilateral, a biopsy should be performed to rule out Bowen's disease or extramammary Paget's disease.

1. As tolerated, add increasing strengths of sulfur, coal tar solution, or menthol (0.25%) or phenol (0.5%) to the above cream, or Vytone cream with hydrocortisone 1%.

2. Intralesional corticosteroid injection therapy. This is very effective. Usually, the minor discomfort of the injection is quite well tolerated because of the patient's desire to be cured. The technique is given in the section on lichen simplex chronicus.

Genital Pruritus

Itching of the female vulva or the male scrotum can be treated in much the same way as pruritus ani if these special considerations are borne in mind.

VULVAR PRURITUS. Etiologically, vulvar pruritus is due to candida or trichomonas infection; contact dermatitis from underwear, douche chemicals, contraceptive jellies, and diaphragms; chronic cervicitis; neurodermatitis; menopausal or senile atrophic changes; lichen sclerosus et atrophicus; or leukoplakia. Pruritus vulvae is frequently seen in patients with diabetes mellitus and during pregnancy.

Treatment can be adapted from that for pruritus ani (see preceding section) with the addition of a daily douche, such as vinegar, 2 tablespoons to 1 quart of warm water.

Vulvodynia is a difficult problem to manage. The sensation of burning and pain in the vulvar area is not uncommon and requires careful etiologic evaluation. Most cases can be managed as a contact dermatitis, but there is a strong psychological element. A minimal dose of haloperidol (Haldol), 1 mg, b.i.d., or amitriptyline (Elavil), 10 mg h.s., is occasionally indicated and effective. Larger doses may be necessary. Scrotodynia is a similar variant in males.

SCROTAL PRURITUS. Etiologically, scrotal pruritus is due to tinea infection; contact dermatitis from soaps, powders, or clothing; or lichen simplex chronicus (see

Treatment is similar to that given for pruritus ani in the preceding section. Notalgia Paresthetica

Notalgia paresthetica is a moderately common localized pruritic dermatosis that is usually confined to the middle upper back or scapular area. A pigmented patch is formed by the chronic rubbing. Some evidence exists for a hereditary factor. EMLA anesthetic cream and capsaicin (Zostrix) cream may be beneficial.

bibliography

Denman ST. A review of pruritus. J Am Acad Dermatol 1986;14:375. Leibsohm E. Treatment of notalgia paresthetica with capsaicin. Cutis 1992;49:335.

Long CC, Marks R. Stratum corneum changes in patients with senile pruritus. J Am Acad Dermatol 1992;27:560.

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