Ward 86 Management Recommendations
Contributors: Ser-Ling Chua, DTM&H, MRCP
Toby Maurer, MD
Pruritus is a common symptom among HIV-infected patients, particularly those not virologically suppressed by antiretroviral therapy (ART). The most common underlying diagnoses in HIV patients are as follows:
Common pruritic skin conditions that can be aggravated by uncontrolled HIV infection or low absolute CD4 T-cell counts
- Xerosis (dry skin)
- Seborrheic dermatitis
Uniquely HIV-associated pruritic skin conditions
- Eosinophilic folliculitis
- HIV papular pruritic eruption (occurs only in tropical regions)
- Staphylococcal folliculitis
- Hepatitis C-associated vasculitis
- Herpes zoster
- Bedbug or flea bites
- DRESS (drug reaction with eosinophilia and systemic symptoms)
- Fixed-drug eruption
Skin conditions caused by chronic scratching and rubbing
- Prurigo nodularis
- Lichen simplex chronicus
- Atopic eczema
Patients whose symptoms or clinical findings do not improve with empiric therapy.
Patients with chronic diseases such as psoriasis that require more than intermittent topical therapy.
Patients with serious drug reactions such as DRESS.
A rash (the morphology and location of which can be very helpful in making a preliminary diagnosis)
Skin findings that have developed because of scratching or rubbing; or
No apparent skin changes
A detailed history that includes:
- The temporal evolution of pruritus and rash, including location, appearance, and change over time
- Recent changes in medications
- Prior history of skin disease
- Contact with pets that might harbor fleas or any people who might have scabies
Physical examination focusing on rash location, morphology (ie, macules, papules, pustules, vesicles, nodules, scaling, coalescence of skin lesions, and dry skin), and the precise location and extent of skin lesions.
Using the information gained from this evaluation to choose the most likely diagnosis (see Table 1).
Symptomatic treatment for pruritus:
- Avoid overwashing and irritation of the skin with soap or shower gels--suggest use of non-soap cleansers (eg, those made by Aveeno, Cetaphil, or Neutrogena).
- Liberal use of emollients or moisturizers twice daily.
- Hydroxyzine 10-25 mg PO at bedtime (can take Q6H during the day if needed) or doxepin 25-75 mg PO at bedtime. Caution should be paid to risk of sedation and cognitive changes with these drugs, particularly in patients over age 65.
First-line treatment for specific skin conditions is included in Table 1).
Our approach to clinical management of pruritus is to choose the most likely cause, empirically treat the condition, and maximize the effectiveness of ART for any patient not fully virologically suppressed. We refer to a dermatologist:
Patients with chronic itching may present with:
Key elements of the initial evaluation should include:
|Table 1. Preliminary Diagnosis and Empiric Treatment for Pruritus|