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Q:

11/17/2020
My patient is a 44 year-old female who came to me for eval of four year history of chronic itching, worse sxs when she gets out of the shower, although sxs are present at other times of day. She has complicated medical hx significant for leukopenia/anemia, anxiety, SLE, Raynauds, sjogrens, migraine, neuropathy and asthma. She has h/o being high risk for BRCA. She has been treated with xyzal bid, Zyrtec, Claritin, allegra, Benadryl and hydroxyzine without relief. Labs including CBC (stable - WBC count 3.1), CMP, Fe studies, Vit B12, Folate, TSH and thyroid abs, tryptase were normal. Medications include trazodone, Benlysta, Symbicort, clonazepam, florinef, gabapentin, plaquenil, meloxicam, nabumetone, pantoprazole, Carafate, tamoxifen, topiramate, venlafaxine, prednisone 5-10 mg daily. She has been on Benlysta since 2013 and recalls having significant itching after first dose. Since then, she takes Benadryl as premedication and reports no increase in itching with further doses. My main question is- what further workup would you recommend? Also, could there be a question of Benlysta causing her ongoing itching?

A:

I thank Dr. Peck Ong for providing the response to your inquiry.

Her normal CMP suggests itch is likely not due to renal or hepatic causes. She is on multiple medications some of which have been associated with pruritus including plaquenil and benlysta. Connective tissue disorders including Sjogrens and SLE have been associated with itch also. Itch correlates with the disease activity of the condition. Unfortunately, the mechanisms of itch are not well-understood in these diseases. Did she have rash also or just itch? If rash is present, consider skin biopsy. The fact that itch is worse after getting out of shower suggests peripheral neuropathy which she has. Would consult her neurologist/psychiatrist in adjusting her medications including gabapentin and trazodone. May also consider doxepin. From allergy standpoint, consider environmental allergy testing if not done already.

References:
1. Samotij D, Szczęch J, Kushner CJ, Mowla MR, Dańczak-Pazdrowska A, Antiga E, Chasset F, Furukawa F, Hasegawa M, Hashizume H, Islam A, Ikeda T, Lesiak A, Polańska A, Misery L, Szepietowski JC, Tsuruta D, Adamski Z, Werth VP, Reich A. Prevalence of Pruritus in Cutaneous Lupus Erythematosus: Brief Report of a Multicenter, Multinational Cross-Sectional Study. Biomed Res Int. 2018 Jul 25;2018:3491798. doi: 10.1155/2018/3491798. PMID: 30148164; PMCID: PMC6083500.

2. Haber JS, Valdes-Rodriguez R, Yosipovitch G. Chronic Pruritus and Connective Tissue Disorders: Review, Gaps, and Future Directions. Am J Clin Dermatol. 2016 Oct;17(5):445-449. doi: 10.1007/s40257-016-0201-9. PMID: 27260190.

3. Ajayi AAL. Itching, chloroquine, and malaria: a review of recent molecular and neuroscience advances and their contribution to mechanistic understanding and therapeutics of chronic non-histaminergic pruritus. Int J Dermatol. 2019 Aug;58(8):880-891. doi: 10.1111/ijd.14252. Epub 2018 Oct 26. PMID: 30362504.

I hope this information helps you with your patient.

Jacqueline A. Pongracic, MD, FAAAAI

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