Generalized Pruritus Evaluation and Management

Initial Clinical Assessment

The British Journal of Dermatology recommends beginning with a focused history, including medication review, travel history, and family history, and complete skin examination, then proceeding with first-tier laboratory testing, for patients with generalized pruritus 1
A medication history should be reviewed, as 20-30% of generalized pruritus cases have a significant underlying systemic cause, according to the British Journal of Dermatology 2
Travel history should be screened for infectious causes, including malaria, strongyloidiasis, and schistosomiasis, in appropriate contexts, as suggested by the British Journal of Dermatology 1
Specific triggers, including water exposure, should be identified, as aquagenic pruritus suggests polycythemia vera, according to the British Journal of Dermatology 3
Associated symptoms, such as weight loss, night sweats, fatigue, jaundice, or neurologic symptoms, should be asked about, as recommended by the British Journal of Dermatology 1

The British Journal of Dermatology recommends ordering a complete blood count with differential, comprehensive metabolic panel, thyroid-stimulating hormone, and fasting glucose or hemoglobin A1C, for all patients with generalized pruritus without obvious dermatologic cause 3
Iron studies, including ferritin, iron, and TIBC, should be checked to identify iron deficiency or overload, as suggested by the British Journal of Dermatology 1

If polycythemia vera is suspected, the JAK2 V617F mutation should be ordered, as it is present in up to 97% of PV cases, according to the British Journal of Dermatology 3
If infection or infestation is suspected, HIV serology, hepatitis A, B, C serology, and parasite screening should be considered, as recommended by the British Journal of Dermatology 1
If malignancy is suspected, chest radiography and CT imaging should be considered, as suggested by the British Journal of Dermatology 3
If cholestatic pruritus is suspected, alkaline phosphatase, gamma-GT, and bile acids should be checked, as recommended by the British Journal of Dermatology 1

In elderly patients, an initial 2-week trial of emollients plus topical steroids should be considered to exclude asteatotic eczema before extensive workup, as suggested by the British Journal of Dermatology 2
Bullous pemphigoid should be considered in elderly patients, as pruritus alone can be a presenting feature, according to the British Journal of Dermatology 2
Sedating antihistamines should be avoided in elderly patients, as they are associated with dementia risk, as recommended by the British Journal of Dermatology (Strength C recommendation against) 2

Regular follow-up is essential when the underlying cause is not immediately evident, as systemic causes may not be apparent initially, according to the British Journal of Dermatology 2
Referral to secondary care should be considered if diagnostic doubt exists or primary care management fails to relieve symptoms, as recommended by the British Journal of Dermatology 6, 2
Reassessment should be considered if initial treatment fails, particularly in elderly patients after a 2-week emollient/steroid trial, as suggested by the British Journal of Dermatology 2

Medication history should not be overlooked, as drug-induced pruritus is common and reversible, according to the British Journal of Dermatology 1
Sedating antihistamines should not be used long-term, especially in elderly patients, due to dementia risk, as recommended by the British Journal of Dermatology 1, 2
Pruritus in elderly patients should not be dismissed, as it may be the first sign of bullous pemphigoid or malignancy, according to the British Journal of Dermatology 2