Itching in the elderly could be a symptom of disease

C hallenging cases are where the excitement is. Exciting but sometimes frustrating, especially when your patient continues to suffer and you cannot do anything about it. Take, for example, the case of an 86-year-old lady, Pat, who was initially seen with generalized itching that lasted longer than eight months. It was that kind of itch which is recurrent. There was no associated rash on her skin, and the itching had increased in severity during a few months. She had undergone treatment with emollients, topical corticosteroids, and oral antihistamines, without much benefit. Her medical history includes pneumonia at present, for which she is currently undergoing treatment, and diabetes that is fortunately controlled. There was no personal or family history of atopy. Physical examination revealed no abnormality in the skin. Her CBC (complete blood cell count), liver function tests, electrolyte (potassium, sodium, chloride) profiles were all normal. Results of iron studies revealed a low serum iron level at 36 μg/dL (reference range, 73-179 μg/dL), although the transferrin level and total iron-binding capacity were normal. This is relevant as iron deficiency anemia is one cause of generalized itching. His total IgE level was elevated at 1621 IU/L (reference range, <100 IU/L). An elevated level of total IgE indicates an allergic process is likely present, but it will not indicate what a person is allergic to. A normal IgE level makes it less likely that a person has allergies but does not rule them out due to the length of time between exposures. In between exposures, a person’s IgE level may drop. Sometimes an individual has a condition that affects the immune system and will not produce normal amounts of immunoglobulins. In this case, a person could have an allergy that is not reflected by the total IgE test result. A very rare inherited disease called hyperimmunoglobulin E and multiple myeloma may also present with elevated IgE. Pat was not on aspirin, opioids (medications that relieve pain) or ACE inhibitors (drugs for hypertension), which are common drugs implicated in generalized itching.

Treatment was started with hydrating creams and supplemental oral ferrous fumarate to increase the iron level. Although the iron level normalized within eight weeks, there was no improvement in the itching. Sedative antihistamine therapy and nonsedative antihistamine therapy also conferred no benefit. An empirical course of prednisolone (30 mg/d), tapered and stopped within three weeks, also had no effect on the pruritus.

Alice, 60, cried out in an exasperated refrain that I had heard endless times in my practice. She just could not stop scratching, which started four months ago, pointing specifically to her lower back area. She described her itch as an unusual kind, like getting eaten up on the inside. An itch that’s coming from very deep within her body. She is not diabetic, no new drugs or allergies for her, no bites or hives and — based on her laboratory tests — no lung, liver, gall bladder or kidney disease. She was neither an alcoholic nor a smoker. Itching started with an external stimuli that to normal people would not even be perceptible, such as a touch on her skin, and persisted for a long time. I checked on all of Alice’s lab tests, including thyroid disease, HIV, allergy profile, hormonal tests, but all showed normal results. So, until such time that I could arrive at a definitive diagnosis, I just prescribed Alice oral antihistamine and topical anti-inflammatory lotion plus humectants. On her subsequent visit, I noticed that she lost weight. According to Alice, she lost around 28 pounds in the last six months that was even before the itching started. I had a clinical suspicion but needed a specific test to confirm it. Alice’s medical history included a treatment for genital warts years ago when she was much younger. She was around 40 years old when she found out she had genital wart. So, for my last attempt to reach a diagnosis, I requested for a Pap smear which turned out positive for cervical cancer.

We’ve all experienced the uncomfortable sensation of itching that causes us to scratch for relief. Given the fact that every adult is covered by about 20 square feet of skin that is constantly exposed to possible irritants, we are all bound to get an itch now and then. But itching in the elderly presents a diagnostic and therapeutic challenge. A thorough history, review of systems, and physical examination are critical to determine the cause. There are frequently only lesions such eczematous changes, lichenification, and excoriation secondary to skin manipulation which may be misdiagnosed as the primary cause. Inflammatory dermatoses are also common (seborrhea, atopy and psoriasis). If the diagnosis is uncertain and rashes are present, a biopsy can help. However, patients may present without a rash and yet itch all over. In this case, a need to investigate for chronic diabetes, renal failure, hepatic causes (hepatitis etc.…), endocrine problems, blood-related problems like lymphoma, leukemia etc.., bone problems, renal impairment, neurological causes, tumors, connective tissue problem, infection such as HIV or, in case of elderly patients, drug-induced causes. Itching remains an often neglected symptom, despite having a profound effect on quality of life, particularly through sleep deprivation. When faced with an elderly patient who has persistent pruritus (itching) or pruritus resistant to treatment, it is crucial for the clinician to maintain a high index of suspicion for systemic disease. Such patients should be investigated to exclude underlying pathology.

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