Pruritus

PRURITUS cutaneus (skin itch), a peculiar sensory disorder (paresthesia), which reflexively generates, even during sleep, the need for scratching. In some cases, itching accompanies visible changes in the skin—symptomatic itch; in others, it exists in apparently normal skin—primary itch. Skin itch is not an independent disease, but only a symptom of an existing ailment, local or general. The sensation of itching should be classified among general senses along with sensations of pain, cold, heat, etc., and is apparently perceived by unmyelinated fibers located in the epidermis. Irritation of these nerves is transmitted to sensory centers. Projection of central irritation to the periphery is also possible. Whether the sensitive fibers of the animal nervous system or sympathetic fibers cause itching is an open question. Since even with the same processes in the skin, itching varies sharply in intensity among different people, it is necessary to attribute considerable importance in the pathogenesis of itching to the factor of individuality, especially the emotivity and excitability of the nervous system, the patient's entire life regimen, etc. Itching arises apparently depending on the damage to nerve endings due to various causes, subdivided by some into internal and external. Such a division, of course, can be accepted only conditionally. A more correct subdivision of itching is that of Darier: a) provoked, b) in dermatoses, c) toxic, d) autotoxic. Internal pathological processes can cause a sensation of itching depending on lesions of the nervous or vascular system. These lesions can be either primary, localized in the nerves, or secondary due to changes in the composition of the blood. Itching can also depend on psychological influences. Even when the causes of itching are eliminated, due to the mere fear of the latter, the itching that was previously caused by somatic causes can be mentally maintained. Distraction of attention or fixation of the latter play a significant role in diseases accompanied by itching. Melancholic psychosis, hysteria, and neurasthenia can be accompanied by itching, especially if organic causes causing itching are also present. However, the exact cause of itching in such cases is not always possible to establish. In the case of hematogenously arising itching, the latter can apparently be caused by blood changes of various characters—both by changes in its morphological composition (leukemia), and by the admixture of toxic substances (drug exanthems), and by autointoxication due to improper metabolism (diabetes, azotemia, etc.). It can be assumed that in autotoxic processes, a whole range of dissimilation products can cause itching, however, it is not yet possible to say definitely which ones and what the pathogenesis of itching is in such cases. At the present time, it is still impossible to explain sufficiently why some skin lesions are accompanied by itching and others are not. It has been noted that itching of any origin manifests itself more strongly at night or even appears only at night. This is explained possibly by warming in bed, and also by the fact that a whole range of factors, both psychological and physical, distract the patient during the day. In some, itching intensifies in winter, in sweaty patients in summer. It cannot be excluded that in some cases itching appears only from certain irritants in individuals sensitized to these irritants. This sensitization can be both monovalent and polyvalent. Thus, "pruritus simplex" can sometimes be attributed to the group of so-called allergoses along with urticaria, prurigo, and eczema. Depending on the intensity and duration of scratching, hyperemia with edema, linear or small punctate excoriations covered with a blood crust, and sometimes eczematization are observed; subsequently, the skin can become lichenified and pigmented. Sometimes, pyoderma joins. With prolonged and intense itching, the nail plates smooth out and become glossy, and their free edge wears down and gives a notch in the central part. The general condition with severe itching is sometimes very strongly disturbed and can result in a picture of severe neurasthenia. A distinction is made for pruritus simplex—itching that is not clinically accompanied by any skin changes. As our knowledge accumulates, the range of diseases classified under this heading decreases. Itching from diabetes (diabetic itch), jaundice, etc., has been excluded. With significant spread of itching, the latter is called universal (pruritus universalis); such universal itching is quite often observed in old age—the so-called pruritus senilis; usually difficult to tolerate, it appears without any visible causes, passes at times, only to occur again after some time. Traces of scratching are not observed with it. Pruritus senilis has remained unexplained until now. The explanation by senile atrophy of the skin is unlikely; it is more likely to seek the cause in metabolic disorders and senile degeneration of the nervous apparatus. General itching is observed in diabetes, liver diseases and especially in jaundice, in cancer of internal organs, in nephritis and diseases of the bladder, in severe constipation, and worms. Itching can arise on the basis of diseases of the genital organs; sometimes it regularly accompanies every menstruation or pregnancy. Itching sometimes reaches significant intensity in hysterics and neurasthenics. In all these cases, itching is a reflection of intoxication. In some cases, tea, coffee, tobacco, and vanilla can cause itching. In cases where itching is limited only to certain areas, it is called pruritus localis; while observed everywhere, it still has favorite places—the anus and external genital organs. Pruritus ani sometimes arises as if without a visible cause; in other cases, proctitis, fissures, pinworms, and hemorrhoids serve as the reason. Scratches and eczematization appear; subsequently, the skin infiltrates and loses elasticity, cracks appear, sometimes very painful, and pyoderma. Itching of the external genital organs can be in men and women, but more often in the latter, affecting predominantly the labia (see below—pruritus vulvae). In men, the scrotum and perineum are more often affected. With itching of the external genital organs, the general condition is strongly disturbed, and insomnia sets in. In these cases, it is necessary to determine the cause as much as possible for the prescription of correct therapy (sugar-containing urine, urine in cystitis, pyelitis, vaginal discharge, worms, hysteria, etc.). (Itching in kraurosis vulvae—see Vulva). Psychological influence and even hypnosis are important factors in the therapy of itching. Alcohol, strong coffee and tea, and spicy food are prohibited. A milk-vegetable diet is recommended. In view of the fact that clothing can also cause itching in some subjects, linen underwear is recommended. A moderately warm bed and a firm mattress also have significance in the sense of eliminating itching; arsenic helps occasionally. Empirical remedies are recommended: sodium salicylate, urotropin, aspirin, phenacetin, etc.; experience has shown that sometimes one helps, sometimes another; sedatives are often resorted to: valerian, bromine, etc. Intravenous injections of 10% sodium bromide, recommended by Lebedev, or sodium silicate: 0.02 per 4 cm³ (Juster) are popular. Sometimes one has to resort to sleeping pills, in extreme cases to narcotics: veronal, sulfonal, luminal, gardenal, and finally morphine. Baths do not always help, but sometimes long warm baths before bedtime have a beneficial effect. Physical methods of treatment are widely used: steam baths, especially indicated for senile or autotoxic itching (S. Vermel); static baths and showers, d'Arsonval currents; X-rays (in a dose of 2-5 H without a filter), especially for localized itching; ultraviolet or infrared rays. Combinations of physical therapeutic agents are also possible, e.g., ultraviolet rays + d'Arsonval currents, etc. A number of authors especially recommend for the treatment of local itching "indirect" deep X-ray therapy, acting on a specific area of either the "posterior spinal roots," or "sympathetic ganglia," or the "spinal cord." This "indirect" X-ray therapy (with or without a filter) often gives a quick effect in so-called secondary itching on the basis of chronic dermatoses (e.g., lichen ruber planus). As for externally applied antipruritic agents, there are no truly effective ones. Indifferent pastes, shake lotions, and adhesive bandages are used. Among external agents that have some therapeutic significance, various tar preparations should be noted. With tar therapy, especially intensive, it is necessary to examine the urine. Epicarin and sulfur are also used, especially in the form of sulfur baths (Sol. Vlemingkx). In general, exfoliating treatment is prescribed, which brings some benefit, although theoretically such treatment is not yet justified. Although the itch-relieving anesthetic properties of carbolic acid are obvious, nevertheless, when used, it requires considerable caution due to its necrotizing properties.

Among other antipruritic agents, one may mention menthol, which by itself can cause irritation (1-2%), chloral hydrate (1%), tartaric acid (1-5%), bromocoll, etc. In particularly persistent cases of pruritus of the perineum, epidural injections (via the sacrococcygeal hiatus) of 5-10 cm³ of a 1% solution of novocaine, or the transection of the internal pudendal nerve or its branches, or the genitofemoral nerve, ilioinguinal nerve, etc., have been used with some success. Some Anglo-American surgeons have successfully resorted to the subcutaneous sectioning of "all" nerve branches around the anus.

3. Pruritus vulvae. Etiology. Itching in the area of the external genitalia is often observed in women as one of the symptoms of various local (inflammatory) diseases, often with Trichomonas vaginalis, etc., as well as with various general disorders (e.g., metabolism, especially in diabetes); Pruritus vulvae is also observed in jaundice as a partial local manifestation of general itching, and in some patients it is most pronounced precisely in the vulvar region. Often, Pruritus vulvae, along with general itching, is observed during menstruation and pregnancy, being in these cases a disease of a general nature, caused by changes in metabolism and in the activity of individual endocrine glands. Some indicate that Pruritus vulvae is often observed in women who are sexually frigid (Poncet). The indicated examples of Pruritus vulvae belong to the category of symptomatic itching (Pruritus symptomaticus) of local or general (hematogenous, toxemic, autotoxic) origin. In the opinion of Veit, all cases of Pruritus vulvae are generally of exclusively symptomatic origin, and changes in the skin of the vulva in this case are always secondary. However, one cannot agree with this. Very often in generally healthy women, especially of climacteric age, one has to observe a more or less widespread peculiar violet-gray coloration, dryness, and cracks on the skin of the vulva. These local changes (undoubtedly primary) are so typical that their mere presence allows for the diagnosis of Pruritus vulvae. The pathological-anatomical picture in this case is as follows: small-cell infiltration of the superficial layers of the skin, extensive disturbances in the integrity of the epithelium (acanthosis, parakeratosis, and especially hyperkeratosis), and uneven thickening of the horny layer, which corresponds to the state of leukoplakia (see) and belongs to the group of hyperkeratoses. These deep changes in the skin and underlying layers can irritate the endings of sensory nerves and therefore cause a sensation of itching. Consequently, leukoplakia of the vulva is a primary phenomenon, and itching in it is a secondary one. Since Pruritus vulvae is observed most often in the pre-climacteric and climacteric age, it is obvious that the leukoplakia itself, which lies at its foundation, is the result of the onset of ovarian hypofunction. These cases of Pruritus vulvae constitute a special category (Pruritus of ovariogenic origin) in the sense of "insufficiency" of the ovary or its dysfunction (Beigel, Dalche, and others). Finally, there are cases of Pruritus vulvae without any primary skin changes [with the exception, of course, of such a (secondary) phenomenon as traces of scratching]. This is already a third variety, of purely neurogenic ("psychogenic") origin, neurogenic Pruritus ("essential" of old authors). The possibility of such an etiology of Pruritus vulvae was pointed out back by Scanzoni and especially Olshausen, then Schubert, who considered Pruritus vulvae a neurosis, Mauclaire, Tavel, and Gibbons, who saw the cause of the itching in changes in the spinal centers, and most of all Walthard, in whose opinion the etiological moment of the itching lies in the pathologically altered mental sphere of the patient. Symptoms and objective data in Pruritus vulvae can be quite different in their intensity—from insignificant sensations appearing only at times, and sometimes periodically regular attacks, to agonizing itching that does not cease day or night (warming in a warm bed always intensifies Pruritus vulvae). During menstruation and pregnancy, Pruritus vulvae usually intensifies. The sensations of itching can sometimes be so strong that some women cannot refrain from scratching, even when in public places. Due to scratching, skin lesions form, which in themselves (especially during urination) cause a sensation of burning and itching. Sometimes, out of a sense of false shame, the patient hides her suffering, does not seek medical help, and brings the disease to the extreme degree of its development (general exhaustion, complete loss of ability to work, sharp depression of the psyche, aversion to life, and even attempts at suicide). Changes in the vulva, noted during examination, are different depending on the etiology. Sometimes the cause of the itching is immediately visible (vulvitis, soot, endometritis with purulent leukorrhea), sometimes the question is resolved after urinalysis (sugar). Often, the above-mentioned changes of a leukoplakic character catch the eye. Only in the neurogenic form are there no typical local changes. In all cases, regardless of their origin, there can always be, as a secondary phenomenon, i.e., as a result of scratching, more or less deep cracks, excoriations, boils, and diffuse inflammation of the vulva. The diagnosis usually does not present difficulties. It is important to establish the etiological moment as accurately as possible, for which (in addition to the anamnesis) the following are necessary: a detailed gynecological examination, examination of urine, discharge from the genital tract (sometimes feces for worm eggs), and, most importantly, a correct assessment of the general state of the nervous system and psyche. Since the most frequent cases of Pruritus vulvae are on the basis of leukoplakia associated with ovarian dysfunction, it is very important to be able to recognize and correctly evaluate both these local leukoplakic changes and the functional disorders of the ovarian-uterine cycle associated with them, which indicate a temporary or final extinction of the activity of the sex gland (oligomenorrhea, prolonged amenorrhea, climacteric). The prognosis should be made with great caution, as in many cases Pruritus vulvae does not respond to therapy immediately or easily. Therapy for Pruritus vulvae must be based on an accurate clarification of the etiological moments, but since these latter often remain unclear, one has to resort to purely symptomatic treatment. Where the cause of Pruritus vulvae is a local disease or some accurately established and curable metabolic disorder, the task is relatively simple. It is more difficult to treat cases of itching associated with leukoplakia of ovariogenic origin, since many details of the biochemical activity of the ovaries and their functional disorders are still unknown, by virtue of which organotherapy is not always effective and is of an empirical nature. Various ovarian preparations have been recommended. Thus, Babesch, Buia, and others obtained good results from extracts of the corpus luteum (internally or subcutaneously), Labhardt and others successfully used various ovarian preparations containing products of the ovary as a whole (2 tablets daily for a long time). Individual authors have successfully used testicular (Gallerand and Meyer) and thyroid (Breymann) opotherapy. In cases of neuro-psychogenic origin, psychotherapy is quite appropriate. In the opinion of Walthard, psychoanalysis and mental suggestion are necessary here: it is necessary to convince the patient that she is organically healthy, to show her the erroneousness of her ideas (sometimes false sensations). Such a method of treatment requires great patience, skill, and tact from the doctor. As symptomatic therapy, a huge number of agents have been proposed, which, however, are far from always reliable and effective. The most important of these agents are the following: thorough mechanical cleaning of the vulva followed by repeated washing with a 1-2-5% carbolic solution (disinfectant and anesthetic effect of phenol), mesotan oil (1:4, according to Olshausen), wetting with a solution of silver nitrate (2-5-10%, according to Labhardt), then cool or even cold sitz baths several times a day, mainly before bedtime (after this, one should avoid excessive wrapping and warming in bed); local application of ichthyol, thigenol, naphthalan, etc., is also recommended. Some authors have successfully used "indirect" deep X-ray therapy, but its effect is rarely lasting. Surgical treatment has also been used—excision of the most itching areas of the skin and removal of the clitoris (the latter intervention was successfully used by Simpson and others). Poncet believes that resection of skin areas can be resorted to if the itching is limited to a small surface; vulvectomy is indicated only in the presence of leukoplakia. The performance of resection of the internal pudendal nerve, genitofemoral nerve, ilioinguinal nerve, resection of the perineal muscles, etc., has not even received relative distribution. Various methods of physiotherapy are widely used at the present time; among them, local application of d'Arsonval currents often gives particularly good results in the treatment of Pruritus vulvae (this has been established empirically by both gynecologists and physiotherapists). Vinges points out that with the help of ultraviolet and infrared rays, it is often possible to cure Pruritus vulvae. Recently (1927), Araya and Roncorini, on the basis of personal observations, insistently recommend epidural injections (from 10 to 20 cm³) of a sterile NaCl solution (or hypertonic). The use of the most diverse internal agents (antipyretica, antinervina, somnifera, narcotica) can have only a palliative significance and is not always harmless (addiction to narcotics).

When Trichomonas vaginalis is present, some authors particularly recommend the Hohne method, which consists of thoroughly drying the entire vaginal mucosa, followed by cleansing with mercuric chloride (1:1,000) and washing with glycerin and borax (30 per 100). This therapy is carried out for a month, 4 times a week, and then only glycerin with boric acid is used.

E. Burdinovsky.