sign in sign up
<<
Home , Antipruritic

Continuing Medical Education

A Practical Review and Update on the Management of Pruritus Sine Materia

Melanie J. Tuerk, BS; John Koo, MD

GOAL To understand pruritus sine materia to better manage patients with the condition

OBJECTIVES Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Describe the 4 categories of . 2. Differentiate between neuropathic and psychogenic pruritus. 3. Assess the utility of pharmacologic and nonpharmacologic therapies for treatment of neuropathic or psychogenic pruritus.

CME Test on page 201.

This article has been peer reviewed and approved Einstein College of Medicine is accredited by by Michael Fisher, MD, Professor of Medicine, the ACCME to provide continuing medical edu- Albert Einstein College of Medicine. Review date: cation for physicians. August 2008. Albert Einstein College of Medicine designates This activity has been planned and imple- this educational activity for a maximum of 1 AMA mented in accordance with the Essential Areas PRA Category 1 CreditTM. Physicians should only and Policies of the Accreditation Council for claim credit commensurate with the extent of their Continuing Medical Education through the participation in the activity. sponsorship of Albert Einstein College of This activity has been planned and produced in Medicine and Quadrant HealthCom, Inc. Albert accordance with ACCME Essentials.

Ms. Tuerk and Dr. Koo report no conflict of interest. The authors discuss off-label use of amitriptyline, anes- thetic , capsaicin, carbamazepine, , doxepin, fluoxetine, gabapentin, lamotrigine, , olanzapine, oxcarbazepine, paroxetine, pimozide, sertraline, and thalidomide. Dr. Fisher reports no conflict of interest.

Pruritus can be divided into several categories: of these types of pruritus present with no evidence pruritoceptive, neurogenic, neuropathic, and psy- of primary cutaneous lesions. The presentation of chogenic. Neuropathic itch is caused by lesions both conditions can be confusing and patients of afferent neural pathways. Psychogenic itch is with no primary cutaneous lesions can be pre- secondary to primary psychiatric disorders. Both maturely diagnosed as having a psychiatric dis- order. Treatment of neuropathic and psychogenic Accepted for publication October 1, 2007. pruritus can be divided into pharmacologic and Ms. Tuerk is a medical student, University of California, nonpharmacologic therapies. used Davis School of Medicine, Sacramento. Dr. Koo is Professor, include topical capsaicin and agents, Department of Dermatology, University of California, San Francisco. Correspondence: Melanie J. Tuerk, BS, 1801 L St, #219, antiepileptic agents, , Sacramento, CA 95814 ([email protected]). selective serotonin reuptake inhibitors (SSRIs),

VOLUME 82, SEPTEMBER 2008 187 Pruritus Sine Materia

and atypical agents. Nonpharma- and updates diagnostic possibilities and available cologic therapies such as psychotherapy and therapeutic options for patients with pruritus that hypnosis have been beneficial. Further studies exhibit no identifiable primary cutaneous lesions are needed, as most reports of efficacy are not and have no apparent systemic medical condition evidence based. accounting for their symptoms. Cutis. 2008;82:187-194. Neuropathic and Psychogenic Pruritus To review the literature on pruritus sine materia, a tch, also known as pruritus, is defined as “an MEDLINE/PubMed search was performed for English unpleasant cutaneous sensation which provokes language articles and abstracts from 1960 to 2006 I the desire to scratch.”1 Itch may be classified by its containing the keywords neuropathic, psychogenic, mechanisms. It is typically divided into one of several pruritus, itch, and therapy. Additional articles were categories: pruritoceptive, neurogenic, neuropathic, obtained by reviewing the references cited in articles and psychogenic.2 Pruritoceptive itch originates in retrieved using the MEDLINE search. the skin, is mediated locally by molecules such as Neuropathic Pruritus—The sensation of itch is histamine, and is transmitted by C nerve fibers. Neu- carried by specialized C fibers that originate in the rogenic itch is caused by circulating mediators acting skin and carry information to the dorsal horn of the centrally, such as opioid neuropeptides in cholestasis spinal cord.2 These fibers are anatomically indistinct acting centrally on opioid receptors. Neuropathic from fibers carrying signals. Itch impulses are itch is caused by peripheral or central nervous transmitted via the spinothalamic tract to the thala- system (CNS) lesions along the afferent neural mus and then to the somatosensory cortex. pathway leading from the skin to the brain. Finally, Pruritus as a solitary or dominant symptom fol- psychogenic itch is secondary to primary psychiatric lowing CNS injury is rare but well-documented in disorders, such as delusions of parasitosis. It is possible the medical literature. Multiple CNS lesions have to have pruritus of more than one type simultane- been implicated, including brain tumors, aneu- ously. For example, a patient with also may rysms, abscesses, multiple sclerosis, stroke, trans- have generalized pruritus secondary to cholestasis. verse myelitis, and spinal cord hemangioma, as well When a pruritic patient is first seen by a phy- as postherpetic neuralgia.3-9 The pruritus that results sician, a thorough history and general physical may be intermittent or constant and onset may or examination are completed and the physician typi- may not be immediate. The distribution often cor- cally looks for primary cutaneous lesions that could responds to a particular spinal segment but may be provide clues to the etiology of the patient’s com- either bilateral or unilateral. Often a sensory deficit plaint. If found, lesions likely would lead the physi- or an aberration in sensory perception such as allo- cian to consider a differential diagnosis consisting dynia (nonpainful stimuli evoke pain), allokinesis mostly of pruritoceptive disorders. If no lesions are (sensation of itch produced by innocuous stimuli present, the condition is known as pruritus sine that would not ordinarily induce itch), or hyper- materia. The next logical step would be to evaluate pathia (evoked pain grossly out of proportion to the patient for an internal etiology for the itch- painful stimuli) is present. ing sensation, such as uremia. Both pruritoceptive One example of neuropathic pruritus is brachio- and neurogenic itch are mediated by identifiable radial pruritus, which is characteristically localized organic causes. to the dorsolateral aspect of the upper arm.10 The Challenging cases arise when patients present etiology is unknown, but one study demonstrated with no primary cutaneous lesions and their exten- cervical spine pathology on radiographs correspond- sive medical workup does not reveal any abnor- ing to the location of pruritus in 11 of 22 patients.11 malities. The physician may be tempted to conclude Notalgia paresthetica, characterized by pruritus on that the pruritus is secondary to some underlying the back in a dermatomal distribution and occasion- psychiatric or supratentorial process and refer the ally associated with pain, paresthesia, or hyperes- patient to a mental health professional; however, thesia, is thought to be attributable to neurologic this conclusion may be premature because neuro- pathology at the spinal level corresponding to the pathic pruritus also is a possibility. If psychogenic affected dermatomes.12 pruritus is ultimately diagnosed, optimal care for Because neuropathic pruritus is caused by neu- patients results from a dermatologist working closely ronal damage anywhere along the afferent neural with a mental health professional. Therefore, it is pathway, it can occur in a specific dermatomal beneficial for dermatologists to be updated on the pattern or in a more broad distribution. Therefore, management of these patients. This article reviews a careful history and a high index of suspicion are

188 CUTIS® Pruritus Sine Materia

required for diagnosis in a patient with no evidence blemishes. The lesions vary in size from a few mil- of pruritoceptive or neurogenic pruritus. limeters in diameter to large craters and often are Psychogenic Pruritus—It is estimated that up weeping, crusting, or scarring, with surrounding to 75% of dermatology patients have a psycho- postinflammatory pigmentation changes.20 Inter- genic component to their skin complaints.13 Most estingly, pruritus is not always predominant in psychogenic skin disorders have an underlying these patients. This behavior can lead to serious psychiatric component of depression, anxiety, complications, such as chronic skin ulcers, exten- obsessive-compulsive disorder (OCD), or psycho- sive scarring, and abscesses. Neurotic excoriations sis.14 Dermatologic diagnoses that are considered often are associated with depression and OCD.21,22 to have a primary psychogenic etiology include If associated with OCD, despite full awareness of delusions of parasitosis, neurotic excoriations, and their behavior and the potential consequences, artefacta. Some conditions, such as pru- patients find themselves unable to cease the rigo nodularis and lichen simplex chronicus, have destructive activity. both psychogenic and physiologic etiology; these Dermatitis artefacta differs from neurotic excoria- disorders have an organic basis but also are strongly tions in that the patients deny their participation in affected by psychologic factors. Because pruritus the development of the lesions and usually use more may be associated with one or more underlying than just their fingernails (eg, sharp instruments, psychiatric diagnoses, it is often difficult to deter- lighted cigarettes) to inflict damage on their skin. mine if the psychiatric disorder is the cause of the These patients typically are unable to give a reliable patient’s pruritus. history regarding the evolution of the lesions. The Depression is commonly associated with psycho- lesions have varying morphology and may present as genic pruritus.15 These patients with psychogenic blisters, purpura, ulcers, erythema, edema, sinuses, or pruritus secondary to depression also may pre- nodules, depending on how they were created by the sent with prominent anxiety and agitation. Careful patient.23 In a study of patients with different forms pharmacologic management is essential, as use of of self-inflicted dermatoses, depressive illness was agents with effects (ie, older found in 46% (12/26).24 benzodiazepines such as diazepam and chlordiaz- epoxide) in the absence of therapy Treatment may exacerbate the underlying depression.16 Dopa- Pharmacologic Therapy—Despite the different etiolo- mine pathways in serious depression also have been gies of neuropathic and psychogenic pruritus, similar implicated in the development of chronic tactile classes of pharmacologic and adjunctive therapies hallucinations that are manifested by sensations are useful for both. A simple approach to therapy for of itching, crawling, and burning in the absence these disorders is to divide treatment types, namely of delusions.17 topical, supportive, and CNS-directed therapies. Patients with monosymptomatic hypochondria- Topical therapy consists of medications directed cal psychosis have a delusional preoccupation at the skin itself. Because the etiology of neuro- with a solitary hypochondriacal ideation (eg, an pathic and psychogenic pruritus is not primarily erroneous belief that one’s skin is infested with cutaneous, it seems unlikely that topical therapy parasites). Hallucinations experienced as formica- would be helpful. However, topical therapy may tion, a sensation of crawling, biting, or stinging, be useful in patients with overlapping central and frequently accompany the delusion. These patients pruritoceptive pruritus. In addition, the empirical typically do not have any other abnormal psychiat- use of topical agents such as a eutectic mixture of ric function.18 The primary etiology is a psychiatric local , an anesthetic agent combining disorder, but healthy skin may be secondarily dam- 2.5% and prilocaine 2.5%, can help dis- aged from manipulation by the patient. The delu- tinguish central from pruritoceptive pruritus. In sion occasionally is experienced by the patient’s addition, anesthetic cream has been effective in spouse or a close relative or friend, as they come to treating notalgia paresthetica.25 Capsaicin, an alka- believe in the delusion. Dopamine pathways have loid isolated from red pepper plants, relieves pruritus been implicated in hallucinations and delusions, as by depleting substance P from cutaneous nerve dopamine-blocking are effective in treating endings involved in pain and itch, resulting in the these symptoms.19 inhibition of itch signal transmission from the skin Neurotic excoriations also have a primarily to the CNS.26 Side effects include localized feelings psychogenic etiology. Patients with neurotic exco- of burning, stinging, and hyperalgesia. Pretreatment riations are driven to pick, scratch, or rub healthy with topical anesthetic creams may reduce these side skin or skin with minor irregularities, such as minor effects.27 Capsaicin has been shown to be effective for

VOLUME 82, SEPTEMBER 2008 189 Pruritus Sine Materia

notalgia paresthetica,28,29 brachioradial pruritus,30 and adverse events. Thalidomide, an immunomodula- prurigo nodularis.31 tory , has shown benefit in treating prurigo Supportive therapies combined with other thera- nodularis.43-45 It is a powerful central depressant peutic options augment overall management of these and has a -related property. In addition, patients. Occlusion of pruritic areas with Unna it inhibits C-fiber function and therefore may boot, Duoderm, or nonlatex gloves may help the have a primary antipruritic effect. It also has anti- patient break the itch-scratch cycle.13 If a patient inflammatory action by which it inhibits synthesis of has identifiable discrete lesions that are pruritic, tumor necrosis factor a, a cytokine that may induce such as prurigo nodularis or lichen simplex chroni- pruritus. The major adverse side effects of tha- cus, intralesional steroid injections, laser therapy, or lidomide are severe fatigue, peripheral neuropathy, cryotherapy may control the pruritus associated with and teratogenicity. these lesions.13,15,32-34 Occlusion alone or combined Antidepressants have demonstrated efficacy in with topical and intralesional therapy reducing pruritus, presumably through neurotransmit- is effective for notalgia paresthetica.15 Goeckerman ter modulation. Tricyclic compounds, such as doxepin, treatment, consisting of daily application of coal and selective serotonin reuptake inhibitors (SSRIs) tar and UVB or psoralen plus UVA phototherapy, have been beneficial in psychogenic pruritus. may provide benefit to patients with pruritus sine Tricyclic antidepressants have antihistaminic materia as well as prurigo nodularis and lichen effects and inhibit the reuptake of norepinephrine simplex chronicus.13,35,36 and serotonin in the CNS and peripheral nervous Central –directed therapy in the system. Although the sedative and antihistaminic treatment of neuropathic and psychogenic pruritus effects of these drugs occur promptly, the antidepres- usually targets the suspected underlying etiology of sive effects can take 2 weeks or longer to manifest the pruritus, such as depression and anxiety. Often, after reaching an adequate dose. However, the however, psychotropic agents are empirically used. negative side-effect profile of tricyclic antidepres- Many of the same medications that show efficacy sants, including cardiac conduction abnormalities, in the treatment of neuropathic pain also demon- seizures, and drug interactions, limits their clinical strate therapeutic effect in neuropathic pruritus. utility. Amitriptyline is effective in the treatment Other than tricyclic antidepressants, there have of postherpetic neuralgia and brachioradial pruritus. been no controlled studies; therefore, the merits Doxepin has shown benefit in the treatment of neu- of most of these options are based on anecdotal rotic excoriations.46 Doses of these agents should be reports. Carbamazepine, an antiepileptic agent, is more conservative in elderly patients. beneficial in pruritus and dysesthesia in multiple Selective serotonin reuptake inhibitors spe- sclerosis.37 Aplastic anemia and agranulocytosis cifically inhibit serotonin reuptake and increase rarely have been reported. Even though there is serotonin synaptic activity. Examples of drugs in a low incidence of these side effects, hematologic this class are fluoxetine, paroxetine, and sertraline. testing at baseline (pretreatment) as well as peri- These drugs have fewer problems with the seda- odic monitoring is recommended. Oxcarbazepine, tive or antihistaminic properties compared with an analogue of carbamazepine, has efficacy in the tricyclic antidepressants, which improves their the treatment of brachioradial pruritus.38 Oxcar- safety profile, but their antidepressant effects also bazepine lacks the hematologic risks associated can take weeks to manifest. Selective serotonin with carbamazepine and does not require monitor- reuptake inhibitors target many of the underlying ing, but it does carry a risk of hyponatremia and psychopathologies in psychogenic pruritus, such as Stevens-Johnson syndrome. Lamotrigine, another depression, anxiety, and OCD. There have been antiepileptic agent, is of benefit in brachiora- many reports of their efficacy in the treatment of dial pruritus but also has been reported to cause neurotic excoriations.21,47-56 Although these drugs Stevens-Johnson syndrome.10 Therefore, oxcarbaze- are associated with fewer serious adverse events pine and lamotrigine should be discontinued at the than tricyclic antidepressants, they can be associ- first sign of drug eruption. Gabapentin, a structural ated with side effects that patients may find dis- analogue of the neurotransmitter g-aminobutyric tressing, including nervousness, insomnia, fatigue, acid, treats epilepsy and postherpetic neuralgia. It weight gain, and sexual dysfunction. Children shows efficacy in the treatment of brachioradial or adolescents taking any of the SSRIs should be pruritus, pruritus induced by multiple sclerosis, and monitored closely for increased depression and pruritus of unknown origin.39-42 Gabapentin should suicidal ideation. In addition, if the is not be discontinued abruptly but rather should be discontinued abruptly, a withdrawal syndrome can tapered gradually to prevent withdrawal-related occur in rare cases, resulting in dizziness, tremor,

190 CUTIS® Pruritus Sine Materia

anxiety, and dysphoria, which may be minimized or therapeutic rapport.62 Rather, a strong physician- avoided by gradually tapering the dose. patient alliance is essential.63 Once a trusting rela- Mirtazapine is a noradrenergic and specific sero- tionship has been established, psychotherapeutic tonergic antidepressant and that has options may be introduced. In dermatitis artefacta, been used for the treatment of psychogenic pruri- a supportive and empathic approach is recom- tus. It facilitates norepinephrine neurotransmission mended, avoiding discussion of the self-inflicted and selectively increases serotonin neurotransmis- nature of the lesions.23,64-67 When a strong thera- sion. Compared with other antidepressants used peutic relationship has been developed, a more for this purpose, mirtazapine has a more favorable insight-oriented psychotherapeutic approach may side-effect profile, with fewer incidences of nausea be helpful.65,68 and sexual dysfunction. However, as with SSRIs, Some patients with pruritus of a psychogenic children or adolescents taking mirtazapine should etiology may have awareness of their participation be monitored for rare occurrence of increased in the development of skin lesions, such as patients depression and suicidal ideation. Anecdotally, mir- with neurotic excoriations. Despite this awareness, tazapine has been effective in reducing nocturnal a trusting physician-patient relationship should still itching in a case of chronic neurotic excoriation, be cultivated before broaching a discussion about with the onset of action within 2 weeks.57 Dis- participation in their disease.69 Once a trusting continuation of mirtazapine resulted in recurrence physician-patient alliance is established, the under- of pruritus. lying psychopathology may be openly discussed Pimozide is an antipsychotic medication that and treated, and nonpharmacologic psychocutane- is useful in the treatment of delusions of parasit- ous interventions may be discussed. The benefits osis.58 Its effect in reducing delusions is mediated of these interventions appear to result from stress primarily by its antidopaminergic effect. However, reduction, the patient’s increased of control the antipruritic effect of pimozide may be attrib- of the illness, and normalization of the psychoneu- uted to its opiate-blocking effect.59 As with other roendocrine function.70 More importantly, these antipsychotic agents, there are many potential side therapeutic strategies do not cause the patient any effects, including prolongation of the QT inter- harm and are likely to improve the patient’s overall val; ventricular arrhythmias; neuroleptic malignant quality of life. syndrome; and extrapyramidal side effects, such as Cognitive behavior psychotherapy and behavior restlessness, acute dystonic reactions, Parkinsonlike techniques coupled with biofeedback, minocycline, symptoms, and tardive dyskinesia. These effects and sertraline were effective in reducing picking usually are dependent on the dose and length of use behavior in a young woman with acne excoriée.70 and are not always reversible on discontinuation of Most reports of the effectiveness of psychotherapy the drug. The extrapyramidal side effects of pimo- are anecdotal. However, healing of neurotic exco- zide may be minimized with the concurrent use riation lesions has been reported for up to 5 years of . after cessation of therapy in 17 of 20 patients who Olanzapine, an atypical antipsychotic agent, has underwent psychotherapy with insight-oriented and shown efficacy in treating neurotic excoriations in behavior components.71 nonpsychotic patients.60,61 Caution should be used trance is defined as a heightened state when prescribing this drug in elderly patients, as of focus that can be helpful in reducing pruritus the risk of cerebrovascular accidents and - while simultaneously inducing favorable physiologic related psychosis is higher in this population. Other changes.70 Direct suggestion while in the hypnotic adverse side effects include hyperglycemia, diabe- state is the most commonly used method of decreas- tes mellitus, neuroleptic malignant syndrome, and ing pruritus.72 In addition, retraining the subcon- tardive dyskinesia. scious through hypnosis to replace a destructive Nonpharmacologic Therapy—Some nonpharma- habit pattern with a more constructive one, called cologic therapies have been anecdotally shown to symptom substitution, can be helpful in patients benefit patients with pruritus of neurogenic and with self-inflicted lesions.73 There have been psychogenic etiology. 2 reported cases of control of acne excoriée using When the underlying psychiatric diagnosis is posthypnotic suggestion.74 obvious to the physician, he/she must first consider if the patient should be confronted with the diag- Comment nosis. If the patient is unable to recognize his/her There is considerable overlap between neuropathic emotional distress, then early confrontation may disorders and psychologic factors. As this review produce anxiety and anger, resulting in loss of demonstrates, the presentation of neuropathic and

VOLUME 82, SEPTEMBER 2008 191 Pruritus Sine Materia

psychogenic pruritus can be similar. In addition, 9. Dey DD, Landrum O, Oaklander AL. Central neuropathic therapy that is effective for one disorder often itch from spinal-cord cavernous hemangioma: a human can be effective for the other disorder. However, case, a possible animal model, and hypotheses about despite the variety of medications used to treat pathogenesis. Pain. 2005;113:233-237. these disorders, it is an underdeveloped field. There 10. Crevits L. Brachioradial pruritus—a peculiar neuropathic is a paucity of controlled studies, and most reports disorder. Clin Neurol Neurosurg. 2006;108:803-805. of efficacy are based on anecdotal evidence. As a 11. Goodkin R, Wingard E, Bernhard JD. Brachiora- result, it is difficult to practice evidence-based medi- dial pruritus: cervical spine disease and neurogenic/ cine when treating patients with neuropathic and neuropathic [corrected] pruritus. J Am Acad Dermatol. psychogenic pruritus. 2003;48:521-524. Neuropathic and psychogenic pruritus constitutes 12. Savk E, Savk O, Bolukbasi O, et al. Notalgia paresthe- an area of medicine in which expertise from special- tica: a study on pathogenesis. Int J Dermatol. 2000;39: ists in the fields of dermatology, psychiatry, and 754-759. neurology would be immensely helpful. Although a 13. Koo JY, Lo RS. Psychogenic pruritus. In: Zylicz Z, dermatologic approach to treating these conditions Twycross R, Jones EA, eds. Pruritus in Advanced Disease. is effective, there also is benefit in therapies typi- Oxford, England: Oxford University Press; 2004:132-150. cally used in psychiatry and neurology. Therefore, 14. Koo J, Lebwohl A. Psycho dermatology: the mind and skin interdisciplinary cooperation between these 3 fields connection. Am Fam Physician. 2001;64:1873-1878. will likely result in optimal treatment of patients 15. Fried RG. Evaluation and treatment of “psychogenic” with neurogenic and psychogenic pruritus. When pruritus and self-excoriation. J Am Acad Dermatol. approaching treatment of patients with these con- 1994;30:993-999. ditions, it may be beneficial to try a multimodality 16. Gupta MA. Evaluation and treatment of “psychogenic” therapeutic approach, using agents from several pruritus and self-excoriation. J Am Acad Dermatol. medical disciplines. 1995;32:532-533. 17. Koblenzer C. Psychologic and psychiatric aspects of Conclusion itching. In: Bernhard JD, ed. Itch: Mechanisms and The diagnosis and treatment of neurogenic and Management of Pruritus. New York, NY: McGraw-Hill; psychogenic pruritus were reviewed and updated. 1994:347-365. Evidence-based studies regarding therapies available 18. Koo J, Gambla C. Delusions of parasitosis and other for these conditions are sparse. Despite considerable forms of monosymptomatic hypochondriacal psychosis. overlap of dermatology, psychiatry, and neurology, general discussion and case illustrations. Dermatol Clin. pruritus sine materia is a neglected area of medicine, 1996;14:429-438. both clinically and scientifically. More interdis- 19. Kapur S, Agid O, Mizrahi R, et al. How antipsychot- ciplinary cooperation and studies are essential for ics work—from receptors to reality. NeuroRx. 2006; further progress. 3:10-21. 20. Griesemer RD, Nadelson T. Emotional aspects of cutane- References ous disease. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al, 1. Rothman S. Physiology of itching. Physiol Rev. eds. Dermatology in General Medicine. 2nd ed. New York, 1941;21:357-381. NY: McGraw-Hill; 1979:1353-1363. 2. Twycross R, Greaves MW, Handwerker H, et al. Itch: 21. Gupta MA, Gupta AK. Fluoxetine is an effective treat- scratching more than the surface. QJM. 2003;96:7-26. ment for neurotic excoriations: case report. Cutis. 1993;51: 3. Liddell K. Letter: post-herpetic pruritus. Br Med J. 386-387. 1974;4:165. 22. Calikusu, C, Yücel B, Polat A, et al. The relation of psy- 4. Bond LD Jr, Keough GC. Neurogenic pruritus: a case of chogenic excoriation with psychiatric disorders: a com- pruritus induced by transverse myelitis. Br J Dermatol. parative study. Compr Psychiatry. 2003;44:256-261. 2003;149:204-205. 23. Lyell A. Prosser White Oration 1975. dermatitis artefacta 5. King CA, Huff FJ, Jorizzo JL. Unilateral neurogenic pru- in relation to the syndrome of contrived disease. Clin Exp ritus: paroxysmal itching associated with central nervous Dermatol. 1976;1:109-126. system lesions. Ann Intern Med. 1982;97:222-223. 24. Krupp NE. Self-caused skin ulcers. Psychosomatics. 6. Sullivan MJ, Drake ME Jr. Unilateral pruritus and nocar- 1977;18:15-19. dia brain abscess. Neurology. 1984;34:828-829. 25. Layton AM, Cotterill JA. Notalgia paraesthetica—report 7. Massey EW. Unilateral neurogenic pruritus following of three cases and their treatment. Clin Exp Dermatol. stroke. Stroke. 1984;15:901-903. 1991;16:197-198. 8. Shapiro PE, Braun CW. Unilateral pruritus after a stroke. 26. Lynn B. Capsaicin: actions on C fibre afferents that may Arch Dermatol. 1987;123:1527-1530. be involved in itch. Skin Pharmacol. 1992;5:9-13.

192 CUTIS® Pruritus Sine Materia

27. Yosipovitch G, Maibach HI, Rowbotham MC. Effect 45. Maurer T, Poncelet A, Berger T. Thalidomide treat- of EMLA pre-treatment on capsaicin-induced burn- ment for prurigo nodularis in human immunodeficiency ing and hyperalgesia. Acta Derm Venereol. 1999;79: virus–infected subjects: efficacy and risk of neuropathy. 118-121. Arch Dermatol. 2004;140:845-849. 28. Wallengren J, Klinker M. Successful treatment of notalgia 46. Harris BA, Sherertz EF, Flowers FP. Improvement of paresthetica with topical capsaicin: vehicle-controlled, chronic neurotic excoriations with oral doxepin therapy. double-blind, crossover study. J Am Acad Dermatol. Int J Dermatol. 1987;26:541-543. 1995;32(2, pt 1):287-289. 47. Biondi M, Arcangeli T, Petrucci RM. Paroxetine in a 29. Leibsohn E. Treatment of notalgia paresthetica with cap- case of psychogenic pruritus and neurotic excoriations. saicin. Cutis. 1992;49:335-336. Psychother Psychosom. 2000;69:165-166. 30. Barry R, Rogers S. Brachioradial pruritus: a symptom of 48. Arnold LM, Auchenbach MB, McElroy SL. Psychogenic neuropathy. J Am Acad Dermatol. 2003;48:825-828. excoriation. clinical features, proposed diagnostic criteria, 31. Stander S, Luger T, Metze D. Treatment of prurigo epidemiology and approaches to treatment. CNS Drugs. nodularis with topical capsaicin. J Am Acad Dermatol. 2001;15:351-359. 2001;44:471-478. 49. Kalivas J, Kalivas L, Gilman D, et al. Sertraline in the 32. Waldinger TP, Wong RC, Taylor WB, et al. Cryotherapy treatment of neurotic excoriations and related disorders. improves prurigo nodularis. Arch Dermatol. 1984;120: Arch Dermatol. 1996;132:589-590. 1598-1600. 50. Simeon D, Stein DJ, Gross S, et al. A double-blind trial 33. Stoll DM, Fields JP, King LE Jr. Treatment of pru- of fluoxetine in pathologic skin picking. J Clin Psychiatry. rigo nodularis: use of cryosurgery and intralesional ste- 1997;58:341-347. roids plus lidocaine. J Dermatol Surg Oncol. 1983;9: 51. Bloch MR, Elliott M, Thompson H, et al. Fluoxetine 922-924. in pathologic skin-picking: open-label and double-blind

34. Lee CT, Tham SN, Tan T. Initial experience with CO2 results. Psychosomatics. 2001;42:314-319. laser in treating dermatological conditions. Ann Acad Med 52. Stout RJ. Fluoxetine for the treatment of compulsive Singapore. 1987;16:713-715. facial picking. Am J Psychiatry. 1990;147:370. 35. Samson Yashar S, Gielczyk R, Scherschun L, et al. 53. Phillips KA, Taub SL. Skin picking as a symptom of Narrow-band ultraviolet B treatment for vitiligo, pruritus, body dysmorphic disorder. Psychopharmacol Bull. 1995;31: and inflammatory dermatoses. Photodermatol Photoimmunol 279-288. Photomed. 2003;19:164-168. 54. Stein DJ, Hutt CS, Spitz JL, et al. Compulsive pick- 36. Karvonen J, Hannuksela M. Long term results of topical ing and obsessive-compulsive disorder. Psychosomatics. trioxsalen PUVA in lichen planus and nodular prurigo. 1993;34:177-181. Acta Derm Venereol Suppl (Stockh). 1985;120:53-55. 55. Ravindran AV, Lapierre YD, Anisman H. Obsessive- 37. Tait CP, Grigg E, Quirk CJ. Brachioradial pruritus compulsive spectrum disorders: effective treatment with and cervical spine manipulation. Australas J Dermatol. paroxetine. Can J Psychiatry. 1999;44:805-807. 1998;39:168-170. 56. Vittorio CC, Phillips KA. Treatment of habit-tic 38. Savk E, Bolukbasi O, Akyol A, et al. Open pilot study on deformity with fluoxetine. Arch Dermatol. 1997;133: oxcarbazepine for the treatment of notalgia paresthetica. J 1203-1204. Am Acad Dermatol. 2001;45:630-632. 57. Hundley JL, Yosipovitch G. Mirtazapine for reducing noc- 39. Winhoven SM, Coulson IH, Bottomley WW. Brachiora- turnal itch in patients with chronic pruritus: a pilot study. dial pruritus: response to treatment with gabapentin. Br J J Am Acad Dermatol. 2004;50:889-891. Dermatol. 2004;150:786-787. 58. Opler LA, Feinberg SS. The role of pimozide in clinical 40. Taylor RS. Multiple sclerosis potpourri. paroxysmal symp- psychiatry: a review. J Clin Psychiatry. 1991;52:221-233. toms, seizures, fatigue, pregnancy, and more. Phys Med 59. Lee M, Koo J. Pimozide: the opiate antagonist hypothesis Rehabil Clin N Am. 1998;9:551-559, vi. and use in delusions of parasitosis. Dermatol Psychosom. 41. Bueller HA, Bernhard JD, Dubroff LM. Gabapentin 2004;5:184-186. treatment for brachioradial pruritus. J Eur Acad Dermatol 60. Garnis-Jones S, Collins S, Rosenthal D. Treatment of self- Venereol. 1999;13:227-228. mutilation with olanzapine. J Cutan Med Surg. 2000;4: 42. Yesudian PD, Wilson NJ. Efficacy of gabapentin in 161-163. the management of pruritus of unknown origin. Arch 61. Gupta MA, Gupta AK. Olanzapine is effective in the Dermatol. 2005;141:1507-1509. management of some self-induced dermatoses: three case 43. Daly BM, Shuster S. Antipruritic action of thalidomide. reports. Cutis. 2000;66:143-146. Acta Derm Venereol. 2000;80:24-25. 62. Koblenzer CS. Psychocutaneous Disease. Orlando, FL: 44. Calabrese L, Fleischer AB. Thalidomide: current and Grune Stratton; 1987. potential clinical applications. Am J Med. 2000;108: 63. Fried RG. The therapeutic waltz. who is leading the 487-495. dance? Arch Fam Med. 1993;2:822-824.

VOLUME 82, SEPTEMBER 2008 193 Pruritus Sine Materia

64. Rook A, Wilkinson DS. Psychocutaneous disorders. 69. Koblenzer CS. Neurotic excoriations and dermatitis arte- In: Rook A, Wilkinson DS, Ebling FJ, eds. Textbook of facta. Dermatol Clin. 1996;14:447-455. Dermatology. Vol 2. 3rd ed. Oxford, England: Blackwell; 70. Fried RG. Nonpharmacologic treatments in psychoder- 1979:2023-2035. matology. Dermatol Clin. 2002;20:177-185. 65. Fabisch W. Psychiatric aspects of dermatitis artefacta. Br J 71. Fruensgaard K. Psychotherapy and neurotic excoriations. Dermatol. 1980;102:29-34. Int J Dermatol. 1991;30:262-265. 66. Sneddon I, Sneddon J. Self-inflicted injury: a follow-up 72. Shenefelt PD. Hypnosis in dermatology. Arch Dermatol. study of 43 patients. Br Med J. 1975;3:527-530. 2000;136:393-399. 67. Spraker MK. Cutaneous artifactual disease: an 73. Braun BG. Psychophysiologic phenomena in multiple appeal for help. Pediatr Clin North Am. 1983;30: personality and hypnosis. Am J Clin Hypn. 1983;26: 659-668. 124-137. 68. Fabisch W. What is dermatitis artefacta? Int J Dermatol. 74. Hollander M. Excoriated acne controlled by post- 1981;20:427-428. hypnotic suggestion. Am J Clin Hypn. 1959;1:122-123.

DISCLAIMER The opinions expressed herein are those of the authors and do not necessarily represent the views of the sponsor or its publisher. Please review complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings, and adverse effects before administering pharmacologic therapy to patients.

CONFLICT OF INTEREST STATEMENT The Conflict of Interest Disclosure Policy of Albert Einstein College of Medicine requires that authors participating in any CME activity disclose to the audience any relationship(s) with a pharmaceutical or equipment company. Any author whose disclosed relationships prove to create a conflict of interest, with regard to their contribution to the activity, will not be permitted to present. The Albert Einstein College of Medicine also requires that faculty participating in any CME activity disclose to the audience when discussing any unlabeled or investigational use of any commercial product, or device, not yet approved for use in the United States. The staff of CCME of Albert Einstein College of Medicine have no conflicts of interest with commercial interest related directly or indirectly to this educational activity.

194 CUTIS®