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Care of the Aging Patient: From Evidence to Action |

Pruritus in the Older Patient:  A Clinical Review

Timothy G. Berger, MD1; Melissa Shive, MD, MPH2; G. Michael Harper, MD3
[+] Author Affiliations
1Department of Dermatology, University of California, San Francisco
2School of Medicine, University of California, San Francisco
3Department of Geriatrics, University of California, San Francisco
JAMA. 2013;310(22):2443-2450. doi:10.1001/jama.2013.282023.
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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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Figure.
The Epidermal Water Barrier

The keratinocytes of the granular cell layer make and secrete lipid into the spaces between corneocytes, the anucleate keratinocytes of the stratum corneum. This lipid is processed by enzymes into lipid bilayers that are an effective water barrier. Individuals of advanced age (>80 years) have reduced lipid synthesis and secretion. Moderately aged individuals (50-80 years) make and secrete lipid normally but have a defect in lipid processing. Patients of advanced age and, to a lesser extent, moderate age both form a less effective water barrier and repair a damaged barrier (caused by irritants such as detergents and soaps) less effectively.

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