Diagnostic Approach to Facial Pruritus

Initial Assessment and Testing

The British Journal of Dermatology recommends a detailed history and skin examination to identify primary versus secondary lesions, and to look for scratch-induced changes, in patients with facial pruritus 1
A medication review is essential, as 20-30% of generalized pruritus cases have identifiable causes, including drug reactions, according to Praxis Medical Insights 2
First-tier laboratory testing, including complete blood count with differential, comprehensive metabolic panel, thyroid-stimulating hormone, fasting glucose or hemoglobin A1C, and iron studies, is recommended when a systemic cause is suspected 2
The British Journal of Dermatology suggests that skin biopsy may be necessary if diagnosis is unclear or bullous pemphigoid is suspected, particularly in elderly patients 1

Polycythemia vera is a hematologic disorder that can cause aquagenic pruritus, and the JAK2 V617F mutation is present in up to 97% of cases, according to Praxis Medical Insights 2
Cholestatic liver disease can cause pruritus, and laboratory tests such as alkaline phosphatase, gamma-GT, bile acids, and antimitochondrial antibodies may be helpful in diagnosis, as recommended by Praxis Medical Insights 4
Uremic pruritus can be treated with optimization of dialysis parameters and normalization of calcium-phosphate balance, according to Praxis Medical Insights 4

Emollients with high lipid content are preferred for maintaining skin hydration, particularly in elderly patients, as recommended by the British Journal of Dermatology 1
Topical corticosteroids, such as hydrocortisone 1% or triamcinolone acetonide 0.1% cream, may be used for mild to moderate inflammatory dermatoses, according to Praxis Medical Insights 2
Non-sedating antihistamines, such as fexofenadine or loratadine, may be used for symptomatic relief of pruritus, as recommended by Praxis Medical Insights 4

An initial 2-week trial of emollients plus topical steroids is recommended to exclude asteatotic eczema before extensive workup, according to the British Journal of Dermatology and Praxis Medical Insights 1, 2
Bullous pemphigoid should be considered in elderly patients with pruritus, and may require skin biopsy and indirect immunofluorescence, as recommended by the British Journal of Dermatology 1