Dermatology & Allergy · Full case

Itch (Pruritus)

NICE CKSRash vs no rashSystemic & lymphoma

Rash or no rash?The first fork in pruritus: itch WITH a primary rash is usually dermatological (eczema, scabies, urticaria, lichen planus, dermatitis herpetiformis); itch WITHOUT a primary rash (only excoriations) points to a SYSTEMIC cause and needs a screening work-up. This single question reorganises the whole differential

Generalised itch, no rash → screen systemicallyItch without a rash can be the presenting sign of liver disease (cholestasis), chronic kidney disease, thyroid disease, iron deficiency, polycythaemia, diabetes, and haematological malignancy. A baseline screen (FBC, ferritin, U&E, LFTs, TFTs, glucose/HbA1c, ± LDH) is warranted

🟣 Lymphoma itchPersistent generalised pruritus with night sweats, weight loss, fever or lymphadenopathy raises Hodgkin/non-Hodgkin lymphoma — examine nodes/spleen, check FBC/film/LDH, and refer on the NICE NG12 suspected-cancer pathway. Itch can precede the diagnosis. Polycythaemia classically itches after a hot bath (aquagenic)

Don't miss scabiesIntense itch (worse at night), burrows in finger webs/wrists/genitalia, and affected household contacts = scabies. Treat the patient AND all close contacts simultaneously with topical permethrin (whole body), wash bedding/clothes; itch can persist for weeks after successful treatment. Crusted (Norwegian) scabies in the immunosuppressed is highly contagious

Drugs & cholestasisMany drugs cause itch (opioids, ACE inhibitors, statins, some antibiotics, allopurinol); and itch with jaundice, pale stools, dark urine signals cholestasis/obstruction — examine for jaundice and check LFTs. Itch in pregnancy (esp. palms/soles, 3rd trimester) → obstetric cholestasis (bile acids, obstetric referral)

Older skin itchesSenile xerosis (dry skin) is a very common, benign cause in the elderly — but still exclude systemic causes and scabies. Emollients, avoiding soap/hot baths, and a humid environment are the mainstay. Asteatotic eczema and lichen simplex from scratch-itch cycles are common

Psychological dimensionChronic itch is exhausting, wrecks sleep, and is bidirectionally linked with anxiety/depression; the scratch–itch cycle is self-perpetuating. Address sleep, mood and the cycle, and consider delusional infestation (fixed belief of parasites with no evidence) sensitively

Treat cause + symptomManagement is twofold: treat the underlying cause, and relieve the symptom — emollients, avoid irritants/heat, antihistamines (sedating ones for night), break the scratch cycle, and specific agents for cholestatic/renal/neuropathic itch. Sedating antihistamines help sleep; non-sedating help urticaria

📋 Clinical Stem — Itch (Pruritus)

A 61-year-old man with 3 months of relentless generalised itch and NO rash, drenching night sweats and weight loss, who thinks his "skin's just dry"

Frank Adeyemi, 61, has had 3 months of relentless, generalised itching that keeps him awake, with no rash — only scratch marks. He assumes his skin is just dry and wants "a strong cream or antihistamine". On questioning he has had drenching night sweats (changing the sheets), has lost about 6kg without trying, and feels more tired than usual. He has no jaundice that he's noticed, normal bowels, takes no regular medications, and there are no affected household contacts. On examination there is no primary rash, but there is some firm, non-tender lymphadenopathy in his neck and axillae. He's keen to leave with something to stop the itch.

This stem tests the central reasoning in pruritus — the rash vs no rash fork — and recognition that generalised itch WITHOUT a primary rash, accompanied by B-symptoms (drenching night sweats, unintentional weight loss, fatigue) and lymphadenopathy, is a red-flag presentation for haematological malignancy (lymphoma) requiring examination of nodes/spleen, blood tests (FBC, film, LDH, ESR) and an urgent suspected-cancer (NICE NG12) referral — NOT simply an emollient and antihistamine. It also tests the broader systemic screen for itch-without-rash (liver, renal, thyroid, iron, polycythaemia, diabetes), the dermatological causes when a rash IS present (notably scabies — contacts, burrows, night itch), drug causes, and symptomatic relief. The SCA challenge is converting the patient's "just dry skin / give me a cream" request into appropriate urgent investigation, sensitively.

Scenario A — Itch, no rash + B-symptoms → lymphoma (this stem) Generalised itch, no rash, night sweats, weight loss, lymphadenopathy. Examine nodes/spleen; FBC/film/LDH/ESR; urgent NG12 haematology referral; symptomatic relief meanwhile.

Scenario B — Systemic itch (no rash), non-malignant Liver (cholestasis), renal (CKD), thyroid, iron deficiency, polycythaemia (aquagenic), diabetes. Screen bloods; treat the cause; symptomatic relief.

Scenario C — Scabies Intense night itch, web-space burrows, affected contacts. Permethrin to patient + all contacts; wash linens; counsel itch may persist weeks.

Scenario D — Dermatological (with rash) Eczema, urticaria, lichen planus, dermatitis herpetiformis, senile xerosis. Diagnose & treat the skin condition; emollients/topicals.

Scenario E — Drug / pregnancy / psychological Drug-induced (opioids, ACEi, statins); obstetric cholestasis (palms/soles, 3rd trimester → bile acids + obstetrics); anxiety/depression & the scratch cycle; delusional infestation.

Key variables to adapt for Rash vs no rash; systemic screen (liver/renal/thyroid/iron/polycythaemia/diabetes); B-symptoms + nodes → lymphoma (NG12); scabies (contacts/burrows/night); drugs; pregnancy (cholestasis); elderly xerosis; mood/sleep & the scratch cycle; symptomatic relief tailored to cause.

Steps:

Step 1

History — Rash or No Rash · Systemic & B-Symptom Screen · Scabies · Drugs · ICE

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The history turns on one organising question — is there a primary rash, or only scratch marks? Itch with a rash is usually dermatological; itch without a rash points to a systemic cause and a screening work-up. Onto that, layer the B-symptom/lymphoma screen, the systemic-cause screen, scabies (contacts, night itch, burrows) and drugs. Frank's itch-without-rash plus night sweats, weight loss and nodes is a lymphoma presentation, not dry skin.

🎓 SCA framing — don't accept "just dry skin"

"I'll definitely help with the itch itself — but a few things you've told me, the night sweats and the weight loss, mean I don't want to just treat it as dry skin. Itching like this, without a rash, can sometimes be a sign of something going on inside the body, so I'd like to examine you and do some blood tests."

The skill is to give symptomatic relief AND reframe the itch as a possible systemic clue — converting a "cream please" request into appropriate urgent investigation without alarming.

1A — The fork, the systemic screen, scabies and drugs

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Tell me about the itch — where, how long, how bad, and is there any rash or just scratch marks?"	Establishes the central fork. A primary rash → dermatological causes; only excoriations (no primary rash) → systemic causes needing a screen. Frank has generalised itch with no rash — pushing the work-up toward systemic disease. Duration (3 months, persistent) and severity (sleep-disturbing) add weight.In SCA: asking "is there a rash or just scratch marks?" and reorganising the differential around the answer is the pivotal step.	No primary rash → systemic screen
🚩 B-symptoms / lymphoma screen"Any night sweats that soak the sheets, weight loss, fevers, or lumps in the neck, armpits or groin?"	The red-flag screen. Persistent generalised pruritus with drenching night sweats, weight loss, fever or lymphadenopathy raises Hodgkin/non-Hodgkin lymphoma — itch can precede the diagnosis. Frank has all of these. This mandates node/spleen examination, bloods (FBC, film, LDH, ESR) and an urgent NG12 referral.	B-symptoms + nodes → lymphoma work-up + urgent NG12 referral.	B-symptoms → NG12 (lymphoma)
Systemic-cause screen"Any yellowing of the skin/eyes, pale stools or dark urine? Swelling, change in urine? Heat/cold intolerance? Tiredness? Itch after a hot bath?"	Itch-without-rash causes: liver/cholestasis (jaundice, pale stools, dark urine), CKD (renal), thyroid disease, iron deficiency, polycythaemia (aquagenic itch after a hot bath), diabetes. These direct the blood screen and, if positive, the cause-specific treatment.	Pointers → targeted bloods; cause-specific treatment.	FBC, ferritin, U&E, LFTs, TFTs, glucose ± LDH
Scabies screen"Is it much worse at night? Any burrows or spots in the finger webs/wrists/genitals? Is anyone else at home itching?"	Intense night itch, web-space burrows and affected household contacts = scabies — a common, treatable cause needing the patient AND all contacts treated simultaneously. Frank has no contacts/burrows, making scabies unlikely, but it must be screened (and is a classic miss).	Night itch + burrows + contacts → scabies (treat patient + all contacts).	Scabies → permethrin to all contacts
Drugs, pregnancy & skin care"What medicines do you take? (If relevant) any chance of pregnancy? How do you wash — soap, hot baths, emollients?"	Drug causes (opioids, ACE inhibitors, statins, allopurinol, some antibiotics); pregnancy itch (palms/soles, 3rd trimester → obstetric cholestasis, bile acids + obstetric referral); and skin-care habits (soap/hot water/dryness) that cause or worsen itch, especially in the elderly.	Drug cause → review; pregnancy itch → bile acids/obstetrics; xerosis → emollients/avoid soap.	Med review; emollients/skin care
Impact — sleep & mood"How's it affecting your sleep and your mood? Is the scratching becoming a cycle?"	Chronic itch wrecks sleep and is bidirectionally linked with anxiety/depression; the scratch–itch cycle perpetuates it. Addressing sleep, mood and the cycle is part of management (and, sensitively, considering delusional infestation where beliefs are fixed and disproportionate).	Sleep/mood impact → treat; scratch cycle → break it.	Address sleep, mood, scratch cycle

1B — Red flags

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Red Flags — itch as a sign of serious disease

Red flag	Why it matters	Action
🟣 Generalised itch + night sweats / weight loss / fever / lymphadenopathy	Hodgkin/non-Hodgkin lymphoma (and other haematological malignancy) — itch can precede diagnosis.	Examine nodes/spleen; FBC, film, LDH, ESR; urgent suspected-cancer referral — NICE NG12
Itch + jaundice / pale stools / dark urine	Cholestasis / biliary obstruction (incl. malignancy).	LFTs; imaging; refer per cause (urgent if obstructive jaundice)
Itch in pregnancy (palms/soles, 3rd trimester)	Obstetric cholestasis — risk to the fetus.	Bile acids + LFTs; obstetric referral
Aquagenic itch (after a hot bath/shower)	Polycythaemia vera (raised haematocrit) — thrombosis risk.	FBC; haematology if polycythaemia
Crusted (Norwegian) scabies / immunosuppression	Highly contagious; underlying immunosuppression (incl. HIV).	Dermatology; treat aggressively; infection control; investigate immune status
Anaphylaxis / acute angioedema (itch + swelling/wheeze)	Airway/circulatory emergency.	Adrenaline; emergency management

1C — ICE

💭 Ideas

"What do you think is causing it — and what were you hoping for today?"

Frank thinks it's dry skin and wants a cream. Surfacing this lets you agree to treat the itch AND explain why the night sweats and weight loss make you want to look deeper — so the investigation feels like thoroughness, not obstruction.

😟 Concerns

"Has anything about it worried you, beyond the itch itself?"

He may have dismissed the sweats/weight loss, or quietly feared something serious. Naming it lets you pitch the urgent work-up sensitively — honest about the need to check, without catastrophising.

🎯 Expectations

"You'd like something for the itch — let me give you that and explain the tests I'd like to do."

Naming the expectation lets you deliver symptomatic relief now while explaining the bloods and referral — so he leaves with help for the itch AND a clear plan for the bigger question.

1D — Psychosocial context

Itch is dismissed — by patients as dry skin, by clinicians as a minor dermatological nuisance. Yet generalised itch without a rash is a recognised harbinger of systemic disease, including lymphoma, and can precede other symptoms by months. The skilled consultation holds two things together: genuine, prompt relief of a miserable, sleep-destroying symptom, and the discipline to ask "is there a rash?" and to screen for the systemic causes and B-symptoms — so that a request for "a strong cream" is met with both comfort and, where indicated, a life-saving work-up.

🔎 Reframing "dry skin"

Explain why this itch needs investigating.

"Dry skin is common and I'll treat the itch — but dry skin doesn't usually cause night sweats and weight loss. Those make me want to check what's going on underneath, to be safe."

⚖️ Thorough, not alarming

Pitch the cancer-pathway work-up proportionately.

"Most of the time these tests are reassuring. Given your symptoms, the responsible thing is to examine you and do some blood tests quickly rather than just hand over a cream."

😴 The misery of itch

Acknowledge the impact and treat it now.

"Itch like this is exhausting and ruins your sleep — that matters, and I'll give you something to ease it tonight while we sort out the cause."

🤝 Holding uncertainty

Be honest while supportive.

"I can't tell you the cause yet, but I'd rather check properly than miss something. Whatever it is, we'll work through it together."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Is there a rash, or just scratch marks?" — the central fork.

"Any night sweats, weight loss, fevers, or lumps?" — the lymphoma screen.

"Worse at night? Anyone else at home itching?" — the scabies screen.

Deductions

Giving an emollient/antihistamine without the rash-vs-no-rash reasoning
Missing the B-symptoms/lymphoma red flags and NG12 referral
Not screening systemic causes (no bloods) or scabies/drugs
Accepting "dry skin" at face value

🔴 Red

Treats as dry skin; cream only; no rash-vs-no-rash logic; B-symptoms/nodes missed; no bloods/referral

🟠 Amber

Recognises itch-without-rash; some systemic screen/bloods; B-symptoms noted but referral slow; ICE partial

🟢 Green

Uses the rash fork; screens B-symptoms + systemic causes + scabies/drugs; examines nodes/spleen; FBC/film/LDH; urgent NG12; symptomatic relief; ICE all three

Step 2

Triage — Red Flags (Lymphoma/Cholestasis) · Systemic Work-up · Routine

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Triage by the rash fork and the red flags: itch-without-rash with B-symptoms/nodes or obstructive jaundice goes onto the urgent cancer/cholestasis pathway; itch-without-rash otherwise gets a systemic blood screen; and itch-with-a-rash is treated dermatologically (with scabies treated promptly). Frank is firmly in the urgent NG12 lane.

🟣 Urgent

Days (cancer pathway)

NG12

Itch + B-symptoms / lymphadenopathyFBC/film/LDH; urgent haematology (lymphoma) — Frank
Obstructive jaundiceUrgent LFTs/imaging/referral
Aquagenic itch + raised haematocritHaematology (polycythaemia)

🟠 Work-up

Systemic screen

No rash

Generalised itch, no rashFBC, ferritin, U&E, LFTs, TFTs, glucose ± LDH
Pregnancy itchBile acids + obstetrics
Treat cause if foundRenal/liver/thyroid/iron/diabetes

🟢 Routine

Dermatological

With a rash

ScabiesPermethrin to patient + all contacts; wash linens
Eczema/urticaria/lichen planusTreat the skin condition
Senile xerosisEmollients; avoid soap/heat

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"Because your itch has no rash and comes with night sweats, weight loss and the glands I can feel, this goes on an urgent pathway — blood tests today and a fast referral — while I also give you something to ease the itch tonight."

Deductions

Treating a red-flag itch as routine dry skin
Missing scabies in a household with affected contacts

Step 3

Examination — Skin (Rash/Burrows) · Nodes & Spleen · Jaundice · Systemic Signs

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Examination confirms whether there is a primary rash, looks for scabies burrows, and — critically in itch-without-rash — examines the lymph nodes and spleen and looks for jaundice and other systemic signs that name the cause.

🔎 Skin

Check	Why
Primary rash vs excoriations only	Defines dermatological vs systemic (Frank: no primary rash).
Burrows (web spaces/wrists/genitals)	Scabies.
Xerosis / asteatotic eczema / lichenification	Dry skin; chronic scratch.
Dermatitis herpetiformis (extensor blisters)	Coeliac-associated.

🩺 Systemic

Check	Why
Lymph nodes + spleen	Lymphoma/haematological malignancy (Frank: cervical/axillary nodes).
Jaundice / hepatomegaly / scratch marks	Cholestasis/liver disease.
Thyroid / signs of CKD / pallor	Thyroid, renal, anaemia/iron deficiency.
General — weight, well-being	Systemic illness/malignancy.

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Narration that scores

"I'll check your skin for any rash or burrows, then feel for any swollen glands in your neck, armpits and groin, check your tummy for an enlarged spleen, and look for any yellowing — these tell me whether the itch is coming from inside."

Deductions

Not examining lymph nodes/spleen in itch-without-rash
Not looking for jaundice or scabies burrows

Step 4

Investigations — The Itch Screen · FBC/Film/LDH · Targeted Tests

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Itch with a typical rash often needs no tests; itch without a rash warrants a systemic screen, with FBC/blood film/LDH/ESR central to the lymphoma work-up, and targeted tests for liver, renal, thyroid, iron and polycythaemia.

🧪 The itch screen (no rash)

Test	Why
FBC + blood film	Anaemia (iron), polycythaemia, abnormal cells (haematological malignancy).
LDH, ESR/CRP	Lymphoma/inflammatory markers.
Ferritin	Iron deficiency (a treatable cause).
U&E, LFTs	Renal disease; cholestasis/liver disease.
TFTs, glucose/HbA1c	Thyroid disease; diabetes.

🔬 Targeted / second-line

Test	When
Bile acids	Pregnancy itch (obstetric cholestasis).
CXR / imaging	Lymphadenopathy/lymphoma staging (specialist).
HIV / immune work-up	Crusted scabies, immunosuppression risk.
Skin scraping / biopsy	Scabies confirmation; uncertain rash.

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"I'll run a blood screen — a full blood count and film, LDH, liver, kidney and thyroid tests, iron and sugar — which covers the main internal causes of itch, including the blood and gland conditions I'm most concerned about given your symptoms."

Deductions

No systemic screen for itch-without-rash
Omitting FBC/film/LDH when lymphoma is suspected

Step 5

Diagnosis — Dermatological vs Systemic · Name the Cause

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Place the itch on the dermatological/systemic axis and name the cause — and, where the picture is red-flag, name the suspected malignancy and act.

Category	Examples / features
Dermatological (with rash)	Eczema, scabies (burrows/night/contacts), urticaria, lichen planus, dermatitis herpetiformis, xerosis.
Systemic (no rash) — benign	CKD, cholestasis/liver, thyroid, iron deficiency, diabetes, polycythaemia (aquagenic).
🟣 Systemic — malignant	Lymphoma (B-symptoms + nodes — Frank); other haematological malignancy.
Drug-induced	Opioids, ACE inhibitors, statins, allopurinol, antibiotics.
Pregnancy / neuropathic / psychogenic	Obstetric cholestasis; neuropathic (e.g. notalgia paraesthetica); anxiety/depression, delusional infestation.

🚩 Itch without a rash is a systemic question

Frank's formulation is generalised pruritus without a primary rash, with B-symptoms (drenching night sweats, weight loss, fatigue) and lymphadenopathy — a red-flag presentation for lymphoma. The plan: examine nodes/spleen, FBC + blood film + LDH + ESR, urgent NICE NG12 haematology referral, and symptomatic relief (emollients, sedating antihistamine for night) in the meantime — treating the misery now while urgently pursuing the cause.

🎓 SCA Checkpoint — Step 5Tasks

Explaining it plainly

"Your itch has no rash, which tells me it's likely coming from inside rather than the skin itself. With the night sweats, weight loss and the glands I can feel, I want to check urgently for a problem in the lymph glands or blood — so I'll arrange fast blood tests and a specialist referral, and give you something for the itch now."

Deductions

Diagnosing "dry skin" despite the red flags
Not naming the systemic/malignant possibility and acting

Step 6

Referral — 2WW Haematology · Hepatology/Obstetrics · Dermatology

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Referral follows the cause: urgent haematology/suspected-cancer for lymphoma red flags (NG12); hepatology for cholestatic liver disease and obstetrics for pregnancy cholestasis; renal/endocrine for those causes; and dermatology for uncertain or refractory skin disease.

Referral	Who / when	Urgency
🟣 Haematology (2WW / NG12)	Itch + B-symptoms/lymphadenopathy/abnormal FBC/film/LDH — suspected lymphoma (Frank).	Urgent · NG12
Hepatology / surgery	Cholestatic/obstructive liver disease (urgent if obstructive jaundice).	Urgent / soon
Obstetrics	Obstetric cholestasis in pregnancy.	Urgent
Renal / endocrine	CKD, thyroid disease as the cause.	Routine
Dermatology	Uncertain/refractory skin disease, crusted scabies, severe eczema.	Routine / soon

🎓 SCA Checkpoint — Step 6Tasks

Stating the threshold

"Because of the glands and your symptoms, I'm referring you urgently to the blood specialists on the fast-track pathway — you'll be seen within two weeks — and I'll do the blood tests today so the results are ready."

Deductions

Not referring lymphoma red flags on NG12
Not referring obstructive jaundice/pregnancy cholestasis urgently

Step 7

Management — Treat the Cause · Symptomatic Relief · Skin Care · Safety-Net

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Management is twofold: treat the underlying cause (urgently where it's serious), and relieve the symptom — emollients and general skin care, antihistamines (sedating at night for sleep), breaking the scratch–itch cycle, and cause-specific agents — with a clear safety-net.

🎯 Treat the cause

Cause	Action
Lymphoma / haematological (Frank)	Urgent NG12 referral; specialist treatment; symptomatic relief meanwhile.
Cholestatic / renal / thyroid / iron / diabetes	Treat the condition (e.g. iron replacement, thyroid treatment, glycaemic control); specific anti-itch agents for cholestatic/renal/uraemic itch.
Scabies	Permethrin to patient + all close contacts simultaneously; wash linens/clothes at high temperature; counsel itch persists weeks.
Drug-induced	Review/switch the offending drug.
Dermatological / xerosis	Treat the skin condition; emollients; avoid soap/heat.

💊 Relieve the symptom

Element	Detail
Emollients & skin care	Liberal emollients; avoid soap, hot baths, overheating; cool environment; keep nails short.
Antihistamines	Sedating (e.g. at night) to aid sleep/break the cycle; non-sedating for urticaria.
Break the scratch cycle	Behavioural advice; treat lichenified areas; cooling agents (menthol).
Mood & sleep	Address anxiety/depression and sleep disruption.
Safety-net & review	Return if jaundiced, new lumps, sweats/weight loss, or not improving; follow up bloods/referral.

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"Here's the plan: blood tests today and an urgent referral to the blood specialists because of the glands and your symptoms; and to ease the itch tonight — plenty of emollient, avoid hot baths and soap, and a sedating antihistamine to help you sleep. Come back sooner if you turn yellow, find new lumps, or feel worse, and I'll chase the results."

Deductions

Symptomatic relief only, ignoring the cause/red flags
Scabies treated without treating contacts/linens
No safety-net / results follow-up

"Doctor, I'm itching all over and it's driving me mad — keeps me up at night. There's no rash, I think my skin's just dry. Can I get a strong cream or some antihistamines to stop it?"

Who you are

Frank Adeyemi, 61. Three months of relentless, all-over itching with no rash — only scratch marks — that keeps you awake. You assume it's dry skin and want a strong cream or antihistamine. If asked, you've had drenching night sweats (soaking the sheets), lost about 6kg without trying, and feel more tired than usual. No yellowing you've noticed, normal bowels, no regular medications, and no one else at home is itching. You're keen to leave with something for the itch and hadn't thought the other symptoms were connected.

Hidden concerns (reveal if explored)

Wants relief (main): the itch is miserable and you're sleep-deprived.

Downplayed B-symptoms: you'll mention the night sweats/weight loss/tiredness only when asked — you didn't connect them.

Fear (if doctor seems concerned): you become worried if it's something serious; you respond to calm, clear explanation.

Clinical details if asked

Generalised itch ~3 months, no primary rash (only excoriations); worse at night (sleep loss)
Drenching night sweats; ~6kg unintentional weight loss; increased fatigue
No jaundice/pale stools/dark urine noticed; normal bowels/urine; no aquagenic pattern specifically
No medications; no affected contacts; no burrows; no recent travel
On examination: no primary rash; firm, non-tender lymph nodes in the neck and armpits (you'll let the doctor "find" these)

Reactions at key moments

If the doctor just prescribes a cream/antihistamine: you're satisfied — so a strong candidate must NOT stop there and should investigate.
On "this needs blood tests and a referral": a bit anxious, reassured by calm clarity; relieved to also get something for the itch.
On the glands being found: surprised; takes it seriously.
Challenge line: "It's just dry skin though, isn't it? Can't you just give me a cream?"

"Honestly, I think it's just dry skin — can't you just give me a strong cream and some antihistamines and save me the blood tests?"

Resolution: Frank is well served if the GP: (1) uses the rash vs no-rash fork and recognises generalised itch without a rash as a systemic question; (2) screens B-symptoms and examines lymph nodes/spleen, recognising night sweats + weight loss + lymphadenopathy as a lymphoma red flag; (3) arranges the systemic blood screen (FBC/film, LDH, ESR, ferritin, U&E, LFTs, TFTs, glucose) and an urgent NICE NG12 haematology referral; (4) also provides symptomatic relief (emollients, sedating antihistamine for night, skin-care advice) and safety-nets; (5) explains it calmly without false reassurance. He is poorly served if simply given a cream/antihistamine and sent away as "dry skin".

🏥

Clinic Quick Reference

Itch (Pruritus) — Clinical Decision Framework

Rash vs no rash · systemic screen · red flags

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🔀 1 — The fork

Itch WITH a rash

Dermatological: eczema, scabies (burrows/night/contacts → permethrin to all), urticaria, lichen planus, dermatitis herpetiformis, xerosis. Treat the skin condition.

Itch WITHOUT a rash

Systemic: screen FBC/film, LDH/ESR, ferritin, U&E, LFTs, TFTs, glucose. Causes: liver/cholestasis, CKD, thyroid, iron deficiency, polycythaemia (aquagenic), diabetes, lymphoma.

🚩 2 — Red flags & relief

🟣 Itch + night sweats/weight loss/fever/lymphadenopathy → examine nodes/spleen, FBC/film/LDH, urgent NG12 (lymphoma). Jaundice/pale stools/dark urine → cholestasis. Pregnancy (palms/soles) → bile acids + obstetrics. Relief: treat the cause + emollients, avoid soap/heat, sedating antihistamine at night, break the scratch cycle, address sleep/mood.

🎓

SCA Quick Reference

Itch — Consultation Playbook

Rash or no rash · screen the systemic · treat cause + symptom

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🎯 The three pivots that pass this case

1 · Rash or no rash

No primary rash (just scratch marks) → think systemic; do the blood screen. With a rash → dermatological (don't miss scabies).

2 · Screen the red flags

B-symptoms + nodes/spleen → lymphoma (FBC/film/LDH, urgent NG12). Jaundice → cholestasis. Pregnancy → bile acids.

3 · Cause + symptom

Treat the underlying cause AND relieve the itch (emollients, sedating antihistamine at night, break the scratch cycle).

⛔ Don't dismiss itch-without-rash as "dry skin" — screen systemically · Don't miss the lymphoma red flags (B-symptoms + nodes → NG12) · Don't forget to examine lymph nodes/spleen and look for jaundice · Don't treat scabies without treating all contacts · Treat the symptom AND pursue the cause

Itch / Pruritus · GP Clinical Reasoning Framework v2 · NICE CKS Itch/pruritus · NICE NG12 Suspected cancer (haematological — lymphoma) · NICE CKS Scabies · obstetric cholestasis guidance

First fork: itch WITH a rash = dermatological (eczema, scabies, urticaria, lichen planus); itch WITHOUT a rash = systemic — screen FBC/film, LDH/ESR, ferritin, U&E, LFTs, TFTs, glucose · Generalised itch + night sweats/weight loss/fever/lymphadenopathy → examine nodes/spleen + urgent NG12 (lymphoma) · Cholestasis (jaundice/pale stools/dark urine), pregnancy (palms/soles → bile acids), polycythaemia (aquagenic), drugs · Treat the cause AND the symptom (emollients, avoid soap/heat, sedating antihistamine at night, break the scratch cycle) · Scabies — treat the patient and all contacts

Teaching clinicians why each step matters — not just what to do · Always consult current NICE CKS and NG12 guidance · Clinical judgement takes precedence over any framework

Itch (Pruritus)

Red Flags — itch as a sign of serious disease

🔎 Reframing "dry skin"

⚖️ Thorough, not alarming

😴 The misery of itch

🤝 Holding uncertainty

Days (cancer pathway)

Systemic screen

Dermatological

🚩 Itch without a rash is a systemic question

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments