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Pruritus in the older patient: a clinical review

Timothy G Berger, Melissa Shive, G Michael Harper
JAMA: the Journal of the American Medical Association 2013 December 11, 310 (22): 2443-50
24327039

IMPORTANCE: Pruritus is a common problem among elderly people and, when severe, causes as much discomfort as chronic pain. Little evidence supports pruritus treatment, limiting therapeutic possibilities and resulting in challenging management problems.

OBJECTIVES: To present the evidence on the etiology, diagnosis, and treatment of pruritus in the elderly and, using the best available evidence, provide an approach for generalist physicians caring for older patients with pruritus.

EVIDENCE REVIEW: PubMed and EMBASE databases were searched (1946-August 2013).The Cochrane Database of Systematic Reviews and the Agency for Healthcare Research and Quality Systematic Review Data Repository were also searched from their inception to August 2013. References from retrieved articles were evaluated.

FINDINGS: More than 50% of elderly patients have xerosis (dry skin). Xerosis treatment should be included in the initial therapy for pruritus in all elderly patients. Calcium channel blockers and hydrochlorothiazide are important causes of pruritic skin eruptions in older patients. Neuropathic pruritus is infrequently considered but may cause localized itching (especially in the genital area) and generalized truncal pruritus (especially in patients with diabetes mellitus). Certain skin conditions are more common in elderly patients, including scabies, bullous pemphigoid, transient acantholytic dermatosis, and mycosis fungoides, and should be considered in elderly patients with pruritus.

CONCLUSIONS AND RELEVANCE: It is important to evaluate elderly patients for dermatological, systemic, and neurological etiologies of itch. A simple-to-apply diagnostic and therapeutic algorithm can be used. Xerosis, drug reactions, and neuropathy should be considered when evaluating pruritus.

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